Referral Form for Health Professionals

If you are a health care professional referring a patient, please fill out this form.  This is only an initial Service Request form and thus please do not provide patient identifiers. We will follow up with you once the case has been reviewed. If you prefer, we can be reached at: 647-853-3455.

Date of Request *

Date of Request

MM

DD

YYYY

Referring Health Professional *

Referring Health Professional

First Name

Last Name

Designation *

Naturopathic Doctor

Medical Doctor

Other

Other

Please indicate health profession if you indicated "Other" above.

Doctor/Clinic email *

Doctor/Clinic phone number *

Doctor/Clinic phone number

(###)

###

####

Clinic address (Optional)

Communication preference *

How would we best reach you?

Phone

Email

Personal visit

Patient age *

Description of Patient Case *

Please limit descriptors such as full name, addresses, etc.

Current treatments rendered *

Patient residence *

CFEMC currently services the greater Toronto area. Does the patient reside within this area?

Yes

No

Comments

Please provide any further pertinent information.

Dear Doctor, 

An Exercise Physiologist will review the case and contact you. Please accept our appreciation to you for considering our partnership in the medical care of your patient. 

We sincerely thank you for all you do,


Cho Fitness & Exercise Medicine Consulting