Physician Referral Form

Please Fax/provide a copy of any relevant reports/Letter from consulting specialist.

Please Note: If you are an Ontario physician and belong to a family health team (FHN, FHT, FHG) you will not be negated for referring to one of our Specialists or Nurse Practitioners.


Reason For Referral

4 + 11 =

Form to Fax

The Clinic Network Canada Inc.

Head Office 
5th Floor 10 Four Seasons Place
Etobicoke, Ontario M9B 6H7
Ph 1 (855) 462-3646
Fax 1 (877) 891-8371

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