FOR MEDICAL PROFESSIONALS ONLY

Send us your referral

An easier way to send us your referral.

Simply fill out this form, attach your referral letter hit “Send”, it’s that simple.

Note that this is for Referring Providers only (doctors, physiotherapists, chiropractors, psychologists & psychiatrists only). If you are a patient please contact the clinic.

Referrer Details

Salutation

Your name

First Name

Last Name

Your email

Please enter your main correspondence email address for your clinic

Your contact phone number

(###)

###

####

Patient Details

Salutation

Patient Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your patient's main presenting condition?

A brief description of your referral

Cervical pain

Thoracic pain

Lumbar pain

Additional information

Please add any pertinent information you think may be necessary to assist with your patient's consultation/treatment

FOR MEDICAL PROFESSIONALS ONLY

Send us your referral

World Leaders in Pain Management & ResearchPrincipal Investigator: Dr Paul Verrills

World Leaders in Pain Management & Research

Principal Investigator: Dr Paul Verrills