Referral Letter - Attention NP Arv - Please note referral letters and patient intake forms take 10-14 business days to process.

We use Hushmail with confidence, knowing we can encrypt emails and web forms containing personal health information while meeting government mandates

Healthcare Providers Name (i.e. Your name)

Name of Your Clinic

Your Email address

Your Phone number

Name of Patient You Are Referring

Patient Birthdate and Health Card Number

Patient's contact information (patients email address & phone number)

Reason For Referral

Checkbox list

Bloodwork request (include specific labs in box below)

SIBO treatment

Low Dose Naltrexone

Hormone Replacement Tx for Women

Other

History of Presenting Illness/Details re: referral

Past Medical History/Diagnoses/Surgeries

Medications (prescribed by patients GP/NP)

Current prescription medications prescribed by YOU

Allergies

File attachments

Add file

Please upload a file

Your information will be encrypted.