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INVEST
NEWS
EVENTS
BLOG
ABOUT
PATIENTS
Clinic Locations
Patient FAQs
Patient Referral Forms
Sleep Aid Program
Privacy Policy
PHYSICIANS
Physician FAQs
SPECIALTY PROGRAMS
Long-term Care Facility and Home Visit Program
VIP Service
Sleep Aid Program
Self Referral – Sleep Aid Form
INVEST
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EVENTS
BLOG
Long-term Care Facilities
Long-term Care Facilities
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2017-10-22T11:52:45+00:00
Name
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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Bahrain
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Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
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Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
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Cook Islands
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Côte d'Ivoire
Croatia
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Cyprus
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Dominican Republic
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El Salvador
Equatorial Guinea
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French Southern Territories
Gabon
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Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
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Mongolia
Montenegro
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Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Home Phone
Cell Phone
Email
*
DOB
Health Card Number
Referral to Service:
Executive (VIP) Service
Clinic Appointment
Telemedicine
Other (enter details below)
Other
Is patient taking anti-coagulants?
Is the patient pregnant, or trying to become pregnant?
Does the patient have a significant communicable disease? (HIV, Hepatitis, ect.)
Does the patient have untreated substance abuse/addiction?
Systemic/Other:
Systemic
Chronic pain: iatrogenic, operative, post traumatic
Immunological condition
Neurodegenerative disease
Inflammatory Polyarthropathy (RA, Gout, other arthritis)
Has the patient been assessed by a Pain Specialist, Neurologist, Rheumatologist or Oncologist
Cancer
Osteoarthritis
Spondyloarthropathy
Fibromyalgia
Neuropathic Pain
Other
Specify your Immunological condition
Specify your Neurodegenerative disease
Describe your Cancer
Describe your Other Systemic Issues
Mental Health
Checkboxes
Anxiety/Depression
PTSD
Sleep disorder
Has the Patient been assessed by a Psychiatrist, GP/Psychotherapist or Clinical Psychologist?
Current Medications:
Medications tried for current condition:
Physician Information:
Referring Physician or Nurse Practitioner
*
Referring Physician Designation:
*
FRCPSC
FRCPC
CCFP
Other
Physician Phone
*
Fax
*
Billing#
*
Prac. ID#
*
Please attach relevant medical history document here
File types allowed (docx, doc, pdf)
Select a Region
*
Select a Region
Atlantic
Ontario
Western Canada
British Columbia
Please select a clinic in B.C.
Burnaby, BC
Chilliwack, BC
Kelowna, BC
Surrey, BC
Vancouver, BC
Please select a clinic in Ontario
Barrie, ON
Bracebridge, ON
Brampton, ON
Burlington, ON
Etobicoke, ON
Hamilton, ON
Kingston, ON
London, ON
Ottawa, ON
Owen Sound, ON
St. Catharine’s, ON
Stoney Creek, ON
Toronto, ON
Windsor, ON
Milton ON
Albany Clinic (Toronto)
Vaughan, ON
Please select a clinic in Western Canada
Calgary, AB
Edmonton, AB
Regina, SK
Saskatoon, SK
Winnipeg, MB
Please select a clinic in Atlantic
Charlottetown, PE
Halifax, NS
Moncton, NB
Saint John, NB
St. John’s, NL
Sydney, NS
Wolfville, NS
Name
Submit
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