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

13 + 10 =

Form to Fax

The Clinic Network Canada Inc.

Address: Building #1 401-5025 Orbitor Dr. Mississauga L4W 4Y5

Telephone: 1-855-462-3646

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