CASE MANAGER REFERRAL FORM

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240 Duncan Mill Road,
Suite 101 North York,
Ontario, M3B 3S6
Phone:(647) 478-8462
Fax: (647) 945-6786

PATIENT REFERRAL FORM

List of relevant medicines / drugs the patient is
using, diagnostic images along with past medical
history is a must for triaging the referral.

We require relevant images, medications and our Pre-consult Questionnaire completed prior to first consultation.
(www.allevioclinic.com/referrals)

  • Allevio physicians will NOT assume sole responsibility for
    prescription management, notably controlled substances.
    Please consider patients expectation prior to referral.
  • 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.

    Patient Information

    Salutation:

    Patient Name:

    First Name

    Last Name

    Date Of Birth:

    Month/Day/Year

    Health Card Number (OHIP #):

    WSIB:

    IF#:

    Patient's Mobile #:

    Patient's Email ID:

    City:

    State / Province:

    Primary Care Physician Details— Mandatory, otherwise referral processing will be delayed

    Primary Physician/Family Physician Name:

    FAX #:


    Reasons for Referral

    Please tick all that apply

    Patient Medical History

    List of medicines/drugs the patient is using

    (Attach a list if necessary):

    Past medical history of the patient

    (Attach supporting documentation, if relevant):

    Page 1 of 2

    Page 2 of 2

    Patient - Diagnostic Images

    Please provide us with all pertinent medical records including MRI, CT, X-ray, NCS/EMG, bone scan or lab(CBC, INR, PTT, Cr) reports, relevant consultations or prior treatment.

    CASE MANAGER’S NAME (First/Last Name)

    Company

    Email

    Phone