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Home
Services
Health Coaching
Pain Management
Weight Management
Mental Health
Advance Care Planning
Virtual Medicine
About
Pricing
News
Health Professionals
Contact
Request Consultation
Make a Referral
Request Consultation
Make a Referral
Make a Referral
For Ontario residents with a valid OHIP card #.
First and last name of referring physician/ NP
Billing #
Secure e-mail
Fax #
Office phone #
Patient Information
First and last name of patient
Health Card # and version code
DOB
Patient’s e-mail
Patient’s phone #
Reason for referral
Patient has consented to this referral.
Clinician and patient agree with method of electronic communication.
Submit Referral