Online Referral Form

Brampton Location: 200-18 Kensington Road, Brampton, ON L6T 4S5

Hamilton Location: 101-25 Charlton Avenue East, Hamilton, ON L8N 1Y2

Phone: 289-752-9388 • Fax: 289-800-9399

Email: referrals@precisioncare.ca • Website: www.precisioncare.ca

Date of Referral

Are you a member of FHO / FHT / FHN? PLEASE NOTE ALL OUR PHYSICIANS HAVE FHO EXEMPTION

Yes No

Location:

Brampton Hamilton

Referring physician information:

Physician Name

Billing Number

Office Phone

Office Fax

Office Address

Patient information:

Patient Name

Patient DOB

DD/MM/YYYY

Address

Health Card Number

Phone

Alternate Phone

*If selecting 'Other' please indicate the reason here:

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