Referral Form
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Contact Us
Fax: 705-230-9928                                              
Telephone: 705-768-6234   
Email: info@pat-clinic.com

370 Burnham St, Unit A 
 Peterborough ON, K9H 1T6

We are a fee for service clinic. We provide in person and virtual appointments.


Patient Name
DOB
MM
/
DD
/
YYYY
Contact number/ email
Parent or Care Provider Name:

Please check which service(s) you are referring to:


Reason for Referral
Referral Source Name 
Referral Source Contact Number 
Please fax growth chart and any extra information if applicable 
For additional information please visit our website.
Please press submit to send this referral.
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