Union Health Network — Referral Form
Please complete and return by email to info@unionhealthnetwork.com, fax to (647) 689-8913, or call (647) 368-7344.
Referring Provider
Provider name & credential
Practice / clinic
Phone
Fax
Email
Date of referral
Patient
Patient name
Date of birth
Phone
Email
Address
Reason for Referral
Presenting concern / region (e.g. TMJ, low back, sciatica, neck, headaches)
Relevant history & prior treatment
Imaging / reports available (type & date)
Current medications relevant to MSK care
Clinical Flags
Notes
Consent & Signature
Referring provider signature
Date
Union Health Network · Unit 16, 9080 Yonge St, Richmond Hill, ON L4C 0Y7 · (647) 368-7344 · Fax (647) 689-8913 · info@unionhealthnetwork.com