Braxia Health Fax Referral Form

  •     Typed referrals are preferred. If hand-written, please ensure the 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.
  I acknowledge the above policies and will complete the form fully.