DUNDAS
PAIN CLINIC
Physician Referral
Fax completed form with supporting notes
FAX: (905) 291-3840 | PHONE: (289) 452-1160
1. Patient Details
OHIP #
Version
Date of Birth
Full Name
Phone
Other Phone
Address
City
Postal Code
Province
Extended health / auto / WSIB insurer (if any):
Referral type:
First referral
Returning patient
Work / auto injury
Substance use history?
Yes
No
2. Referring Provider
Name
CPSO / CNO #
OHIP Billing #
Clinic
Tel
Fax
Clinic Address
Is this patient rostered to you?
Yes
No
Practice model:
FHO
FHT
FHG
CCM
Other
3. Clinical Details
Pain location:
Head / Migraine
Neck
Shoulder
Back
Hip
Knee
Other
Service:
Consult & Meds
Joint/Bursa Injection
Trigger Point
Botox for Migraine
Assess & Treat
Pain for:
< 3 months
3–12 months
> 1 year
Urgency:
Routine
Urgent
Working diagnosis, history & treatments tried:
Please attach
Cumulative patient profile
Recent imaging and specialist notes
Medication list (flag blood thinners)
Allergies
Sign-off
Signature
Date
801 Dundas Street East, Mississauga, ON L4Y 4G9 ·
info@dundaspainclinic.ca
Subject: