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Physician Referral Form

Dear Physician,

We appreciate your trust. We will update you on your patients’ treatment program and their progress.

  • Download referral forms in PDF, complete and submit by email (please go to the bottom of this page)
  • Complete the Physician Referral Form below and click the ‘Send’ button to submit
  • Contact our clinics directly at 416-444-4800 

Once you submit a request through our web site or by fax, your patient will be contacted to schedule an appointment.

We value your trust to our care and gladly waive the $75.00 assessment fee for your patients who are referred to our two very popular programs:

GLA:D for Hip & Knee Osteoarthritis

Dizziness & Balance Exercise Program/VRT

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PHYSICIAN INFORMATION
Physician NamePhysician name
Physician Phone Numberyour full name
PATIENT INFORMATION
Patient First Nameyour full name
Patient Last Nameyour full name
Contact Phone Numberyour full name
DIAGNOSIS
Please provide Diagnosis heremore details
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OTHER INFORMATION
Other Information (Optional)more details
0 /
Date of your Next Appointment with this Patientof appointment
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Physician Referral Forms (PDF)

Please download one or more of the following referral forms to complete and submit by email to: donmills@physiomobility.ca. 

General Patient Referral Pad
Pelvic Health Physiotherapy Referral
GLAD Program Referral
Vestibular Physiotherapy Referral Pad