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Please, fill this form for your patient referral

Patient's First Name and Last Name*

Patient's Date of Birth*

Health Card #*

Patient's Contact Phone Number*

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Referring Physician's First Name and Last Name*

Location for Referral Chatham or Cambridge, ON*

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send us referral form by fax

Please DOWNLOAD referral form in the format you need, fill it and send as via Fax using contacts below

Referral form IPC All Locations (docx)

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Referral form IPC All Locations (pdf)

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Intervention Pain Clinic in Cambridge, ON

Unit 102, 1150 Franklin Boulevard, Cambridge, Ontario, N1R 7J2

Ph: 519 620 0606

Fax: 519 620 9339

e-mail: ipc.cambridge@yahoo.com

1150 Franklin Boulevard, Cambridge, Ontario N1R 7J2, Canada

Intervention Pain Clinic in Chatham, ON

547 Queen Street, Chatham, Ontario, N7M 2J4

Ph: 519 360 9000

Fax: 519 360 9006

e-mail: interventionpainclinic@gmail.com

547 Queen Street, Chatham, Ontario N7M 2J4, Canada

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Chatham, ON
Cambridge, ON
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