Burlington clinic

Patient referral form

For referrals to the Burlington clinic. Self-referrals may also use these fields.

Online referral: all fields are required. Supporting documents can be faxed to 1-866-359-0432.

Clinic777 Guelph Line, Suite 203
Inside Burlington Centre

Phone / fax1-855-709-4263
Fax 1-866-359-0432

Patient Name *

Patient Phone Number *Canada/US format, for example 905-555-1234 or +1 (905) 555-1234 ext. 5.

Referral Source *

Enter Date *

Diagnosis & Services Requested *

Download Burlington PDF referral pad