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Referral Form

The Ability Clinic

755 Queensway East, Suite 304 Mississauga, ON, L4Y 4C5

Thank you for choosing The Ability Clinic. Please fill out this form to ensure that your patient receives the appropriate care. All information is Private and Confidential

Patient Information

Name:

Date Of Birth:

Phone 1:

Phone 2:

Referring Provider

Name:

Date Of Referral:

Address

Fax:

Specialty:

Billing:

Medical

Physician

First AvailableSpecific Request

Specialty:

As Appropriate

Rheumatology

Physical Medicine and Rehabilitation

Lifestyle/Preventative Medicine

Neurology

Sports Medicine

Service:

Electrodiagnostic Testing (NCS/EMG)

Ultrasound-Guided Injection (cortisone, HA, PRP, nSTRIDE)

Neurology

Botulinum Toxin Injection (migraine, spasticity)

Body Composition Testing (DEXA scan included with Lifestyle Consultation)

Recovery & Wellness

Physiotherapy:

OrthopedicPelvicVestibularCancer

Massage:

RelaxationActive ReleaseCancer

Other:

OrthoticsCustom BracingDEXAShockwave Treatment

Additional Information:

Investigations Attached:

ImagingLabsEMGEEGBone scanOther

Add Attachments

8390

Physicians

Referral
( Online)

Referral
( Paper)

https://abilityclinic.ca/wp-content/uploads/2024/03/New-referral.pdf

Please note: We do not perform fluoroscopic-guided spinal intervention procedures.

For this, we strongly recommend our trusted community partner Bloor Pain Specialists.

755 Queensway East Suite 304

Mississauga, ON L4Y 4C5

P: (905) 826 – 4048

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Ability Clinic

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