PHYSICAN REFERRAL FORM FOR PHYSIOTHERAPY

Doctors,

Thank you for your referral, and we appreciate your trust. We will update you on your patients’ treatment program and their progress.

There are three ways to refer your patient:

Complete the Physician Referral Form below and please click the SUBMIT button to send to our clinic.

Download the referral form, complete and submit by email to info@londonphysicaltherapyclinic.com or fax to 519-433-6186.

DOWNLOAD REFERRAL FORM

Contact our clinic directly by calling us at 519-433-6713

Once you submit a request through our website, fax or email, your patient will be contacted to schedule an appointment. We do not have a waiting list currently.

Physician Referral From

Patient First Name

Patient Last Name

Patient Phone

Patient Email

Diagnosis & Notes

Referring Physician Name

Referring Physician OHIP Billing Number

Physician Phone

Physician Email

Treatment Treatment At Physiotherapist Discretion Specific (add to notes above)

Please select: Please select: OHIP EHC PRIVATE W.S.I.B. MVA