Chronic Pain Referral Form

Please review the exclusion criteria before sending a referral.
Exclusion:
- Age less than 18 years old
- Urgent/emergent cases
- Active or poorly controlled substance abuse disorders
- Active or poorly controlled mood disorders
- Cancer-related pain
- Pain less than 3 months in duration
I have read and understood the above:*

I agree

Referring Physician Information
Name*

First NameLast Name
Billing Number*
Are you in a FHO/FHT

YesNo
Would you consider de-rostering your patient if they could be seen more quickly??

YesNo
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Email
example@example.com

Patient Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OHIP number*
Version Code*
Date of Birth*

MonthDayYear
Date

Patient's medical history
Reason for referral
List current active medical conditions
List any past medical conditions
List current medications and doses
List current medications and doses
List past treatments and reason for discontinuation
List past treatments
Imaging or other relevant reports

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you may submit multiple documents separately if needed
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Should be Empty:

Please review the exclusion criteria before sending a referral.

Exclusion:

Referring Physician Information

Patient Information

Patient's medical history