TRILLIUM SPINE CENTER

referral

A COMPREHENSIVE FACILITY DEDICATED TO SPINAL HEALTH

Patient Info & Clinical History

Please fill in your details below to make an online referral to the Trillium Spine Center. Your information will be submitted via email.






    REFERING PHYSICAN



    PATIENT INFORMATION


    Coverage



    OHIP Information






    Diagnosis

    Clinical History

    SPECIFIC CLINICAL HISTORY

    CONSULTATION REQUIRED


    Neurology Consultation


    PHYSIATRY CONSULTATION


    Sports Injury and Regenerative Medicine


    Nerve Conduction Study/ Electromyography (NCS/EMG)


    Interventional Pain Management/Injection


    PRE-OPERATIVE PHYSICAL THERAPY ASSESSMENT


    POST-OPERATIVE PHYSICAL THERAPY


    PHYSIO TRAINING SESSION & PROTOCOL DEVELOPMENT


    MULTIDISCIPLINARY REHABILITATION PROGRAM (specify protocol below)


    GAME READY


    ORTHOTICS


    Post Surgical Follow up


    TREATMENT PROTOCOL



    LIST ALL CURRENT MEDICATIONS



    INVESTIGATION TO-DATE






    SPECIALIST CONSULT NOTES






    ACKNOWLEDGMENT

    I give my consent to release my personal contact and health information to Trillium Spine Center for the provision of the above-mentioned treatment and services.