Patient Referral Form

○ Barrie ○ Brampton ○ Etobicoke ○ Downtown ○ Mid-Toronto ○ Oakville ○ Ottawa ○ Vaughan/Thornhill

PATIENT INFORMATION:

Name: DOB: (first name) (last name) (dd/mm/yyyy) Health Card : Version Code:

Address: (number) (street name) (unit)

(city) (postal code) (e-mail address)

(home #) (work # with extension) (other #)

REASON FOR REFERRAL LOCATION (SPECIFY)

Foot Care Biomechanics Right Left Diabetes Risk Custom-made Orthotics: Pediatric Pes Planus Assessment & Education Biomechanical Assessment Intoeing/Outoeing Gait & Gait Analysis Wound Management Arthritis Plantar Fasciitis Nail & Callus Care Flat Feet Metatarsalgia Fungal Nail(s) High Arches Bunions Athlete’s Foot Leg Length Discrepancy Ingrown Nail(s) Morton’s Neuroma ______cm/in Wart(s) Tendonitis/osis Ankle/Knee/Hip/Back Pain Compression Therapy Corticosteroid Injection Varicose Veins Spider Veins OTHER: Edema/Lymphedema Pregnancy

Notes: Current Medications:

Referred By : Referring Physician Billing #:

Referring Physician Signature:

Date:

New Patient Referrals: T: 1.844.LMC.FOOT (562.3668) F: 1.877.LMC.APPT (562.2778) E: [email protected] W: www.LMC.ca Our Locations

N LMC BARRIE N LMC BRAMPTON FAIRVIEW RD HIGHWAY 400 BAYVIEW DR BIG BAY POINT RD 370 Bayview Drive 2979 Bovaird Drive E

Suite 110 AIRPORT RD Brampton, ON L6S 0C6 Barrie, ON L4N 8Y2

BOVAIRD DR E T 905.595.0560 T 705.737.0830 F 1.877.562.2778 MAPLEVIEW DR F 1.877.562.2778 LA TIM HORTONS FITNESS

N LMC ETOBICOKE N LMC DOWNTOWN TORONTO EDWARD ST UNIVERSITY AVE CHESTNUT ST KIPLING AVE DIXON RD 123 Edward Street

1723 CENTRE AVE

Suite 2B BAY ST Suite 1500 Etobicoke, ON M9R 4E1 Toronto, ON M5G 1E2

T 416.645.1035 T 416.237.0104 F 1.877.562.2778 F 1.877.562.2778 NORTHCREST RD DUNDAS ST W

LMC OAKVILLE HOSPITAL GATE N N LMC MID-TORONTO THIRD LINE

3075 Hospital Gate BAYVIEW AVE 1929 Bayview Avenue Suite 301 Suite 107 Oakville, ON L6M 1M1 Toronto, ON M4G 3E8 H KILGOUR RD T 905.337.0040 T 416.645.2929 DUNDAS ST F 1.877.562.2778 F 1.877.562.2778 EGLINTON AVE

N LMC VAUGHAN/THORNHILL TARTAN DR N LMC OTTAWA VICEROY RD HIGHWAY 416 FUTURITY GATE 1600 W 4100 Strandherd Drive. DUFFERIN ST Unit 5 Suite 208 Vaughan, ON L4K 3B9 STRANDHERD DR BORRISOKANE RD Ottawa, ON K2J 0V2

T 905.763.8660 T 613.505.9704 F 1.877.562.2778 F 613.505.9707 STEELES AVE