Physician Referral Form — Upper Room Pain Clinic

Upper Room Pain Clinic

Physician Referral Form

Oakville, Ontario

Phone: 647-910-5359

Fax: 289-644-0255

oakville@upperroomclinic.com

Instructions for Referring Physician:

Please complete all sections of this form and fax to 289-644-0255 along with any relevant imaging reports, consultation notes, and medication lists. Our team will triage the referral and contact the patient within 48 hours.

Date of Referral

Section 1 — Patient Information

Last Name

First Name

Date of Birth (DD/MM/YYYY)

OHIP Number

Phone Number

Email Address

Address

Section 2 — Referring Physician Information

Physician Name

CPSO Registration Number

Clinic Name

Clinic Phone

Clinic Fax

Section 3 — Clinical Information

Primary Diagnosis / Reason for Referral

Pain Location(s)

CervicalThoracicLumbarSacralHead/FaceUpper extremityLower extremityAbdominal/Pelvic

Other / Specify:

Duration of Pain

< 3 months3–6 months6–12 months1–3 years3+ years

Current Medications (relevant to pain management)

Previous Treatments Tried

Relevant Imaging / Investigations (please include reports)

Service Requested (if known)

Nerve BlockTrigger Point InjectionProlotherapyProlozonePRP TherapyPRP with Visual GuidanceArthrosamidAssessment Only

Urgency

RoutineSemi-urgentUrgent

Section 4 — Referring Physician Signature

Signature

Date

Upper Room Pain Clinic — A division of The Upper Room Clinic

Oakville, Ontario | Phone: 647-910-5359 | Fax: 289-644-0255 | oakville@upperroomclinic.com

This form contains personal health information protected under PHIPA. Please handle and transmit securely.