Test Page - Ability Clinic

Patient Information

Name:

Date Of Birth:

Phone 1:

Phone 2:

Referring Provider

Name:

Date Of Referral:

Address

Fax:

Specialty:

Billing:

Medical

Physician

First AvailableSpecific Request

Specialty:

As Appropriate

Rheumatology

Physical Medicine and Rehabilitation

Neurology

Lifestyle/Preventative Medicine

Service:

Electrodiagnostic Testing (NCS/EMG)

Ultrasound-Guided Injection (cortisone, HA, PRP, nSTRIDE)

Neurology

Botulinum Toxin Injection (migraine, spasticity)

Body Composition Testing (DEXA for Osteoporosis or Sarcopenia)

Recovery & Wellness (summer 2024)

Physiotherapy:

OrthopedicPelvicVestibularCancer

Massage:

RelaxationActive ReleaseCancer

Other:

OrthoticsCustom BracingDEXAShockwave Treatment

Investigations Attached:

ImagingLabsEMGEEGBone scanOther

Personal Health Information that is medically relevant has not been disclosed at the
request of the patient.

Add Attachments

Please return by Fax:(905) 826-7201 or
E-mail:
referrals@abilityclinic.ca

Fee Schedule

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