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Durham Spine & Sports Clinic - Referral Form
Please complete this referral form for you patients and click submit, we will contact your patient in 24-48 hours to schedule an appointment. If we are unable to reach your patient, we will contact you to confirm the information. Thank you for you referral!
103-420 Green Street, Whitby, ON L1R 8N1 | Tel: 289-638-3086 | Fax: 289-638-3087
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Patient Name
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Your answer
Patient Phone Number
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Your answer
Referring Doctor's Name
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Your answer
Referring Doctor's Phone Number
*
Your answer
Patient Diagnosis/Complaint
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Your answer
Suggested Treatment
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Examination/Second Opinion
Chiropractic
Physiotherapy
Spinal Decompression
Acupuncture
Active Release Technique
Graston
Custom Orthotics
Compression Socks
TENS Unit
Other:
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