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» OHIP Referral Form
Locations:
Downtown
- 179 Queen Street East
Midtown
- 15 Glenforest Road
PHYSIATRY, REHABILITATION, & PAIN MANAGEMENT - OHIP REFERRAL FORM
Patient Information
First Name
Last Name
Birth Date
Gender
Male
Female
Address
Email
Cell Phone
Disciplines Needed
Physiatry (OHIP)
Headaches
Concussion/mTBI
Spinal Pain Management
Assistive Device Clinic
TMJ Clinic
Joint Injections
Allied Health (Private Pay)
Physiotherapy
Occupational Therapy
Speech Language Pathology
Chiropractic
Massage/Acupuncture
Psychotherapy/Clinical Counseling
Orthotics/Stockings/Braces
Diagnosis:
Payer Information
OHIP
Motor Vehicle Accident
Extended Health Care
Long-term Disability/Private Pay
WSIB
Other:
Referrer Information
Name/Title
Billing #
Contact Information
Has client been informed of referral?
Yes
No
Date
OHIP Referral Form
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Chiropractic Care
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Occupational Therapy
Custom Orthotics
Naturopathic Medicine
Shockwave Therapy
Laser Therapy
Bracing
Independent Medical Examinations
MVA Rehab
Clinical Counseling
