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Physician Referral
Referring Physician/Nurse Practitioner First & Last Name
Phone
Fax
OHIP Billing Number
Address
Patient Information
Patient First & Last Name
Health Card Number
Phone
Email
Reason(s) for referral:
Bioidentical Hormone Replacement (BHRT)
Thyroid Dysfunction
Testosterone Therapy
Comprehensive Preventive Health Evaluation
Urinary/Sexual Health
Other
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