Forms

Dear referring physicians: Please feel free to use our referral form below to involve us in the care of your patients, or send us a quick note regarding the reason for referral along with any relevant investigations. Our form can also be found in PSS, Oscar, and Accuro community folders for your convenience. 

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

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

Bloor Pain Speciality

The below is a PDF previewer and you will not be able to save any fields completed. Please download the PDF version, use our Ocean e-referral platform, or follow the methods outlined above.

The Ability Clinic

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

Referral Form

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




    Referring Physician Information









    Physician Requested:


    Consultation and Service(s) Requested:


    Investigations Attached:

    Please return by Fax:(905) 826-7201 or E-mail:
    referrals@abilityclinic.ca

    Physicians

    Referral
    (Online)

    (OR)

    referral
    (Paper)

    Fee Schedule