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 .