FAX REFERRAL FORM

Physiotherapy for the alleviation of symptoms related to cancer such as pain, lymphedema, fatigue, loss of function, breathlessness and reduced range of movement.

FROM:                   ___________________________________

            Address:           ___________________________________

                                    ___________________________________

            Phone:              ___________________________________

TO:                         Attention: Kitty (Caryl)Martinho

                             ACTION POTENTIAL REHAB  

                             Physiotherapy Service

                             72 Nanook Cres. Kanata, Ontario K2L 2A8

                                    Tel: (613) 228-0777

                                    FAX: (613) 723-3584

DATE:                                                                                               

PATIENT:               ___________________________________

            Address:          ___________________________________

                                    ___________________________________

            Phone:             ___________________________________

REASON FOR REFERRAL:

OTHER MEDICAL/SURGICAL HISTORY:                               

MEDICATIONS/TREATMENTS:

__________________________________________________

___________________________________________________________________________

The information contained in this fax is personal and confidential and intended for the use of the individual or entity to which it is addressed. If you have received this message in error  note that any distribution, dissemination or copying of this information is prohibited. Please immediately contact Action Potential Rehabilitation. Thank you.