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

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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