Refer someone

If you are a medical professional and would like to refer someone, please use this secure form to submit your request.

All information provided through this form will be stored confidentially. This solution is safer and faster than faxing us a prescription!

We will be in touch with your patient soon and will put them in contact with one of our qualified physiotherapists. Feel free to contact us if you have any questions.

Name of the patient

Please enter the contact information for the patient you would like to refer. This information will be stored confidentially.

First Name

Last Name

Email of the patient

Phone number of the patient

(###)

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Reason for referral

Please indicate the reason for referral and other relevant information (e.g., prescription or treatment preferences). This information will be stored confidentially.

Name of the person referring

Please enter your contact information so that we can reach out in case we need more information.

First Name

Last Name

Profession of the person referring

Email of the person referring

Phone number of the person referring

(###)

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Clinic you are working at (if applicable)

I am a patient