Referring Practitioner Info

Referral Form

Our physicians hold a Focused Practice Exemption in Pain Management, ensuring NO negation for FHO physicians.

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Complex Regional Pain Syndromes (CRPS/Regional Sympathetic Dystrophy (RSD); refer to McMaster or St. Joseph’s Pain Management Centres)
Opioid Use Disorder (refer to local addiction/dependency clinic)
Peri-operative pain
Chronic pelvic pain (refer to McMaster Pelvic Pain program)
Cancer pain (refer to hospital pain/palliative care services)
No valid OHIP card
Routine opioid prescribing; we can assist with opioid assessments/suggestions, or MEQ>90 reviews.

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Patient Name: *

OHIP # (with valid VC)

Date of Birth: *

(Note: We only accept adult patients > 18years old)

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Contact Phone #: *

Email address (if available):

Address

Address Line 1

City

State

Zip Code

Additional Insurances/Benefits (circle all that apply):

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Duration of Pain:

Upper Limb

Pain Locations

Lower Limb

Relevant History/Investigations/Treatments:

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**Please attach CPP, all recent imaging and laboratory investigations, prior consult notes, and prior/current medications (allergies)