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Referral Form

For Physicians Only
Please use this form to refer patients for ultrasound-guided injections. You may submit the completed form using the online submission below.

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Dr. Sherif El-Maadawy MB B Ch, MSc, FRCP(C), Master-CIME, Physiatrist
Dr. Brian Loewen MD, CCFP, Dip. Sport Med.

Patient Information

Address
Gender

Dr. I. El-Gouhary MB B Ch, LMCC, CCFP, CIME
Dr. Joel Schiendel MD
Dr. O. Vicaruddin MD, PgCPain, CIME

Physician Information

Physician Address
Active WCB

Referral Information

Services Required

Indicate specific services required: