For referring providers.

• Patient name, date of birth and phone number
• Referring physician or provider name, clinic and contact details (and billing number if applicable)
• Diagnosis or reason for referral
• Relevant history, imaging or test results
• Surgery type and date, and the surgeon's protocol if post-operative
• Precautions, contraindications or restrictions (weight-bearing status, range of motion limits, etc.)
• Treatment requested (e.g. physiotherapy, vestibular, pelvic health, Registered Massage Therapy) and frequency if specified
• Insurance or funding details if known (WSIB, MVA claim number, extended health)

Fax to 905-669-6995 or email derrick@vaughanphysiotherapy.com. If you're a physician referring a patient, let us know and we'll keep you updated on their progress.