Dr. Tyson Sawchuk

Alberta Mental Health Line

If this is an emergency, call:

Crisis Line: (877) 303-2642
911

We take information security seriously. This is a secure webform which is transmitted encrypted and compliant with the Health Information Act of Alberta. Information is stored within Canada, not shared with other agencies or governments and not used for any other purposes than the medical referral.

YOU CAN ALSO FAX A REFERRAL AS LONG AS IT HAS THE SAME INFORMATION: +1 (587) 441-8380

Patient Information

First name

Last name

Email address

Phone number

Province

Existing Client

Date and Time

Date of Birth

Sex Assigned at Birth

Female Male Prefer not to indicate

Preferred Pronouns

Referring Physician

Referring Physician First and Last Name

PRACID (Alberta)

Fax Number

Address

The patient has been informed that the referral is for private services that will be billed to the patient.

Patient is not concurrently receiving or seeking services at Alberta Children's Hospital for Functional Neurologic Disorder (FND)

About Your Appointment

Brief Medical History

If there's anything else that you would like me to know prior to your appointment, please include it here.

Files

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Disclosure

MAGIC Clinic Ltd. does not charge membership fees. Fees for psychology services that are not covered by insurance or a provider are billed directly to the patient. No payment is required to request an appointment. You should inform your patient that you are requesting a consultation with a specialist that will be directly billed. The patient will be made aware of any charges before they have an appointment.

Your information will be encrypted.