Professional Referral Form

If you belong to a family health team (FHO, FHT) you will not be negated for referring to our physicians
or one of our anaesthetists. New CCFP physicians are in the process of obtaining their practice exemption
and we will promptly notify our referring physicians on their status. Please fill out all fields that apply.

Download PDF Form

Please download our referral form and fax accordingly to: InMedic London Fax: 519.601.7174 InMedic Windsor Fax: 519.735.0588 InMedic Kitchener Fax: 519.208.8182

Referring MD / Allied Health Professionals

Do you belong to a:*

Possess Valid Opiate Prescribing License:*

If Different, Please Provide Family MD Details

Patient Information

Patient Information

Are you the patients family Physician or most responsible Physician?*

Javascript is required to submit this form.