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Patient Referral Form for Physicians
Patient Phone (Home):
Patient Phone (Mobile):
Patient Health Card #:
Please indicate pending medical procedure:
PMHx: (Please list or provide supporting documentation)
Medications: (Please list or provide supporting documentation)
Please indicate that your patient agrees to be involved in a medical weight loss program and is motivated to reach your specified weight loss goal.
What is your weight loss goal?:
While our clinic offers both in person and virtual visits, if your patient would benefit from a virtual visit, they must be willing to engage in video consults and email, to best serve them in terms of quality of care, and in keeping with the CPSO’s standard of clinical care. Please indicate that your patient is able to take advantage of these technologies.
Please include copies of recent bloodwork, ECG, cardiac investigations and sleep studies (if applicable), Medications lists or medical history:
Upload supported file (Max 15MB)
OHIP Billing #:
Submit Referral Form