Physician's Referral Pad

Making Referrals

The Physician’s Referral Pad is a helpful tool developed by the Hand and Upper Limb Clinic designed to ease to the referral process and get our patients directly onto the road to recovery. Surgeons and other physicians may use this tool to quickly make a referral for their patients, whether it’s post-operative patients, patients requiring injury rehabilitation, or those simply experiencing a lack of functionality/mobility due to a worsening medical condition, the Physician’s Referral Pad help gets patients the care they need.

  • Click on the link below and print out the designated page.
  • Get the patient to fill out their personal information and preferred method of payment.
  • Fill out the patient’s medical diagnosis, the procedure they had done, the date of onset for the injury and/or surgery, and any recommendations/suggestions you may have to promote the patient’s recovery.
  • You may then send the form with the patient or fax it to us here at the clinic at: 807-344-9030

Click Here to refer your patients to the Hand & Upper Limb Clinic.