Professional Referral Form
Referral of patient to the Alliance Healthcare Professionals Inc.

Date: 05 Apr 2004

Patient Name: ________________________________________________

Phone : ( ____ ) _________________________

Referred By : Dr. ______________________________________________

Type of Patient:  MVA    WSIB     Private

Diagnosis:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Doctor's Comment/Concerns/Contraindications/Treatment Objectives:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Motor Vehicle Accident Assesment
Physiotherapy
Athletic Therapy
Chiropody (foot care)
Massage Therapy
Acupunture
Orthopedic bracing
Orthodics
Swiss Ball Program
Sports Injury
Other

Doctor's Signature : __________________________________________

Doctor's Phone Number : ( ____ ) ____________________

Written Report Requested    Yes    No

 232 South Service Road
Oakville, Ontario  L6J 2X5 Canada
tel: 905-845-2291 fax: 905-845-5606
[email protected]