Referrals

Thank you for referring your patients to us. Please fill in the electronic referral form below.
You can also click here to download PDF form to fill it out manually.
Please fax the completed form to us at 1 866 816 3464.

1. Date( MM/DD/YYYY) *

2. Introducing *

3. Birth Date (MM/DD/YYYY) *

4. Guardian *

5. Relationship *

6. Address *

7. City *

8. Postal codes *

9. Home phone *

10. Other phone

11. Email

12. Reason for Referral / Comments *

13. Radiographs*
 None Meditran/Doc Services by Mail with Patient


14. Primary Insurance? *
 Yes (Please answer #15-#20) No (Please skip to #21)

15. Name of insured

16. Employer

17. Plan name

18. Policy no.

19. ID no.

20. % of Coverage


21. Secondary Insurance? *
 Yes (Please answer #22-#27) No (Please skip to #28)

22. Name of insured

23. Employer

24. Plan name

25. Policy no.

26. ID no.

27. % of Coverage


28. Referred by *

29. Phone *

30. Appointment date *
 Please contact patient for making an appointment Patients to call to make an appointment

31. Your office is located in? * (e.g. Vancouver BC)

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