Braxia Health Fax Referral Form

  •     Typed referrals are preferred. If hand-written, please ensure writing is legible or we will be unable to process the referral.
  •     We will only accept a fully completed form.
  •     Please ensure that the patient’s health card is up to date.
  •     Please ensure that the patient meets the clinic’s inclusion/exclusion criteria.
  •     For our French language form please contact the Montreal clinic direct at (514) 481-7867 or send an email to [email protected].
  I acknowledge the above policies and will complete the form fully.