Physician Referral Referring Physician/Nurse Practitioner Information * First Name Last Name Phone * (###) ### #### Fax (###) ### #### OHIP Billing Number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Patient Information * First Name Last Name Health Card Number Phone (###) ### #### Email Reason(s) for referral Menopause/Peri-Menopause Therapy Thyroid Dysfunction Testosterone Therapy Comprehensive Health Assessment & Disease Prevention Urinary/Sexual Health Nutrition Other Thank you!