Atma Medical Clinic | Referral Form

PATIENT INFORMATION

First Name *

Last Name *

Gender Male Female Neutral

Date of Birth *

Health Card # *

Address

City

Postal Code

Email (Required)

Phone Number (Home / Work / Mobile Please Specify) Home Work Mobile

REASON FOR REFERRAL

Medical Cannabinoid Assessment Continuation of Care for Cannabinoid Therapy Cannabis Education Only

DIAGNOSIS OR INDICATION FOR REFERRAL (Check all that apply)

Chronic Pain (RA, OA, MS, MSK, Spasticity, Neuropathic)
(Non-cancer related pain) Post-traumatic Pain (MVA, etc.) Inflammatory Polyarthropathy Cancer Pain Inflammatory Bowel Disease Multiple Sclerosis Spondyloarthropathy Fibromyalgia Other :

MENTAL HEALTH (Check all that apply)

Anxiety PTSD Depression Sleep Disorder (Insomnia) Other :

This patient is currently being treated for a mental health disease. Dx:

This patient is under the care of a licensed psychiatrist, psychologist, psychotherapist for mental health treatment. Practitioner's Name:

DOES YOUR PATIENT HAVE ANY OF THE FOLLOWING? (Yes or No)

PHYSICIAN INFORMATION

*Indicates required field

Physician Name *

Billing Number *

Date

Practitioner Address

City

Postal Code

Phone

Fax

Are You Member of FHO or FHTs *

Yes No

I,

, hereby attest that the medical record entry above for

accurately reflects signatures/notations that I made in my capacity as

as the referring physician/practitioner. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification will deem this referral null and void.

*Please attach additional CPP (Cumulative Patient Profile), diagnostic imaging, laboratory investigations and specialist consult notes (Pain Specialist, Neurologist, Rheumatologist, Oncologist, Orthopedic Surgeon, Psychiatrist). Documentation MUST be provided for patient visit.

ONLINE REFERRAL FORM TO BE COMPLETED BY A PHYSICIAN/PRACTITIONER ONLY