Name:
OHIP:
Date of Birth:
Phone:
Address:
Email:
Patient consents to receive email/text messages
Referring Provider:
Billing Number:
Fax/Email:
Primary Care Provider:
Active WSIB
Location of Pain:
Referral Pattern:
Duration of Pain:
Clinical Summary:
Urgent Assessment
Reason:
First Available Pain Physician
Specific Pain Physician:
Sports Medicine
Physiatry
Comprehensive Pain Consult
Interventional Pain Referral
Specific Procedure:
Please send all relevant previous imaging for patient. Please send relevant images with each consult. Please provide MRI, CT, US, X-Rays if requesting infusion therapy. Please perform baseline ECG.