fax form to 647 427 4100 - allevioclinic.com · 240 duncan mill road, suite 101 patient referral...
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PAT I E NT R E F E R R A L FO R M 240 Duncan Mill Road, Suite 101
North York, Ontario, M3B 3S6
Phone: 647 478 8462
Fax Form to
647 427 4100
Allevio physicians will NOT assume sole responsibility for prescription management, notably controlled substances. Please consider patients expec-
tation prior to referral
Please note that the Allevio Pre-Consult Pain Questionnaire (www.allevioclinic.com/referrals) must be completed by patient.
Normal time for processing referrals at Allevio is 2 to 3 weeks
Incomplete referrals may result in delayed consultation
We will contact patients directly for appointments.
Date: □New Patient □Re-referral
P a t i e n t I n f o r m a t i o n
Patient Name: Date of Birth:
Last name First Name Middle Month / Date / Year
Patient’s OHIP #: WSIB: □ Male □ Female
Patient’s Mobile #: Patient’s Email ID:
P r i m a r y C a r e P h y s i c i a n D e t a i l s — M a n d a t o r y o r e l s e r e f e r r a l p r o c e s s i n g w i l l b e d e l a y e d
Primary Physician / Family Physician Name: Fax #:
P a t i e n t — D i a g n o s t i c I m a g e s
Area of Pain for Treatment (Circle only) Please tick ( ) all that apply
○ Neck Pain ○ Back Pain ○ Radiculopathy ○ Headache
○ Fibromyalgia ○ CRPS / RSD ○ Persistent Post—Surgical Pain
○ MVA—related (Lawsuit) ○ Neuropathic pain
Specific intervention
○ Lidocaine Infusion ○ Platelet Rich Plasma
○ Osteopathy ○ Chiropractic ○ Acupuncture ○ Bracing
○ Other:
R e a s o n s f o r R e f e r r a l
P a t i e n t M e d i c a l H i s t o r y
P l e a s e p r o v i d e u s w i t h a l l p e r t i n e n t m e d i ca l r e c o r d s i n c l u d i n g MR I , C T , X – r a y , NC S / E M G , b on e
s c a n or l a b ( C B C , I N R , P T T , C r ) r e p or t s , r e l e v a n t c o n s u l t a t i on s o r p r i or t r e a t me n t .
REFERRING PHYSICIAN’S NAME (PRINT CLEARLY) REFERRING PHYSICIAN”S SIGNATURE OHIP PROVIDER #
List of relevant medicines/drugs the patient is using
(Attach a list if necessary):
Past medical history of the patient (Attach supporting docu-
mentation, if relevant):
List of relevant medicines / drugs the patient is using, diag-
nostic images along with past medical history is a must for
triaging the referral .
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