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Referral Information

To access our services you can contact us directly by phone at 613-722-3222, by fax at 613-722-4652 or by using our on-line referral form.

A referral from a physician is not necessary, however most extended health insurers require a physician referral for reimbursement.

Referral Form:

Please fill in all the fields below:

Client Information:
Referral to:
Client Name:
Client Address:
City:
Province:
Postal Code:
Home Phone:
Work Phone:
Fax:
Cell Phone:
Date of Birth:
Can we leave a message at home?
Can we leave a message at work?
   
Referral Information:
Referral Name:
Referral Address:
City:
Province:
Postal Code:
Work Phone:
Fax:
Email:
Notes:


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