Follow the steps to successfully complete the referral form.

1. Press the ‘Get Form’ button to retrieve the form and open it in your chosen editor.
2. Enter the date and the patient's details, including their full name, date of birth, OHIP number, and WSIB number if applicable.
3. Provide the patient's contact information by filling in the phone numbers for home, cell, and work.
4. Select all reasons for referral by checking the relevant options related to the patient’s condition, ensuring to print clearly.
5. Specify any particular interventions if the patient is seeing pre-approved providers.
6. Indicate the patient's condition type by selecting from options such as acute, chronic, cancer-related, or palliative.
7. Answer whether the patient has visited the emergency room due to pain in the past six months and provide the number of visits if applicable.
8. Determine if a return to work is realistic with better pain management; select the appropriate option.
9. Indicate any allied services requested, such as chiropractic or psychotherapy, that might benefit the patient’s care.
10. Attach any pertinent medical records that support the referral, including diagnostic reports and treatment history.
11. Ensure the Allevio Pre-Consult Pain Questionnaire is completed by the patient and returned before scheduling an appointment.
12. Have the referring physician print their name and provide their signature, OHIP provider number, and contact details.
13. Once all fields are completed, save your changes. You can then download, print, or share the completed form as needed.

Begin filling out the Allevio Pain Clinic Referral Form online today to ensure seamless processing of your referral.