Form for Physicians

GENERAL PHYSICIAN REQUISITION






Additional Instructions for Patients







Instructions:

Step 1:

Open the "General Physician Requisition" by clicking the download button on this page.

After clicking the button it should automatically download the requisition to your computer.

*If your device does not automatically download the requisition go to the top right of the pdf page to click on the download button manually.

Step 2:

Open the pdf file on your computer with a pdf editing software ( Adobe, Microsoft Office, etc.) and fill in your patient's information digitally.

*If you do not have a pdf editing software or do not wish to complete the form digitally; print the requisition, fill in the information by hand, and re-scan it with the completed information.

Step 3:

After the form is completed, please fax it to us at the fax number provided below

Fax: +1 (289) 722-2023

OR Give the requisition to the patient to bring in person. The patient can also text us a picture of the requisition (905) 897-6970.

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