Health Professional Referral
Please complete the referral form below and the MSRS Intake Worker will contact you within two business days.
You will receive a copy of your referral via email for your records.
Your Contact Number:
Client's Date of Birth:
Client's Contact Number:
Medication(s) of Concern
Prescription opioids (eg. oxycodone)
Over-the-counter opioids (eg. codeine)
Benzodiazepines (eg. diazepam)
Consent Obtained for Referral
Yes - my client has provided informed consent and would like the MSRS Intake Worker to contact them directly.
No - I do not have consent from my client to make a referral. Please contact me to discuss further.
How did you hear about us?
Thank you for contacting us. The MSRS Intake Worker will contact you within two business days to discuss your referral.
A copy of your responses will be emailed to the address you provided.
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