Orthotics and Referral Requests

Eglinton Medical Centre & Med Square Medical Centre 15

Eglinton Medical Centre & Med Square Medical Centre

Date / Time

First Name

Last Name

Gender

Date of Birth

Health Card

OHIP Health Card Number & Version Code Or UCI number for IFHP (BlueCross)

Do the patient have a family doctor ?

Please write the name of the family doctor or the clinic

Patient Phone Number (patient will be called on)

You may need to pay for your appointment

$75 doctor fees for Private pay.

Patient Phone Number (patient will be called on)

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Name of Physiotherapy Centre

Email of the centre to send the Rx or referral after confirm with patient

What Rx or Referral needed? please write down all Rx needed for this patient

Physiotherapy assessment, please upload all related assessment to support your request. Mandatory for all patients for all ages. Please in PDF

Choose File

Privacy and Consents

The Physiotherapy Centre, as noted above, confirms that the patient's information is accurate.

We confirm that the patient has been informed and has provided consent to be contacted by the physicians for verification prior to any prescriptions or referrals being issued.

We acknowledge that if the patient does not respond to the physicians’ calls, no prescriptions or referrals will be provided.