Physician Referral Form

REFERRING PROVIDER INFORMATION

Practitioner (CPSO, CNO) Number

Referring Physician Name

Clinic Name

Address

Phone

Fax

Registration (Billing) Number

Signature

Date

PATIENT INFORMATION

Patient Name

Date of Birth (DD/MM/YYYY)

Health Card Number (include version code)

Address

City

Postal Code

Phone

Alternate

Email (optional)

Family Physician (if different)

Reason for Referral

Chronic Low Back Pain

Neck Pain

Radicular Pain (Sciatica / Cervical Radiculopathy)

Post-Surgical Pain

Neuropathic Pain

Joint Pain (Shoulder / Knee / Hip)

Cancer-Related Pain

Complex Regional Pain Syndrome

Other:

Duration of Pain

< 3 months

3–12 months

> 12 months

Relevant Medical History

Previous Treatments Attempted

Physiotherapy

Chiropractic

Massage Therapy

Medications (please list below)

Injections (specify type/date)

Surgery

Other

Type of assessment

Urgent assessment

Yes

No

Reason:

Specific procedures

Yes

No

Reason:

All referrals must be accompanied by the relevant imaging and Investigations

X-ray

Ultrasound

MRI

CT

EMG

Other:

Goals of Referral

Diagnostic Clarification

Interventional Pain Procedures

Multimodal Pain Management

Other:

Please attach

Relevant consultation notes

Imaging reports

Medication list

Upload Documents (Optional)

Accepted formats: PDF only. Max 5MB.