Physician Referrals

GWC Online Referral

If you are a doctor and would like to refer a patient to our clinic for any of our services, please download and fax a referral to our clinic, OR you may complete this Online Referral Form for your convenience!

Complete Patient Information Below

Firstname

Lastname

Sex/Gender

Other specify

Date of Birth

Health Card Number

Version Code (XX)

Home Phone

Mobile Phone

Patient Address

Patient Email

REASON for Referral

History of Present Illness

Past Medical Health

Medications

Attach supporting documents

(JPG,GIF,PNG,TIF,PDF only)

Referring Physician Name

OHIP Billing Number

Referral MD Email

Comments

Consent to Shared Care

I agree to the Terms and Conditions at Get Well Clinic:

I hereby refer the above patient for assessment and treatment at Spring Health (“SHC”) | Get Well Clinic (“GWC”) with Dr. Lai and Associates. I agree to shared care with Get Well Clinic. The declare the practitioners at Get Well Clinic are hereby considered part of the patient's circle-of-care.

I understand and agree that the health care practitioners will assess and treat the patient to the best of their knowledge and abilities, in accordance with their training and qualifications. Due to the nature of medicine as not an exact science, I understand and agree that in rare circumstances, medical errors can occur. I agree to be a full participant in working other healthcare providers to avoid any errors that may occur. If I am not confident of the care my patient receiving, I understand that I am also free to get a second opinion on my own seeking. If I am not satisfied with the care that I receive, I will endeavor to communicate and work with the healthcare providers and staff at GWC to resolve any issues. I will endeavor to be courteous when I communicate with the doctors and office staff, and also when I relay my positive or negative experiences to others regarding the care my patient received.

I also declare the following:

I declare that I am an authorized health record custodian and have obtained consent from the patient for transmitting patient health information to Get Well clinic. I understand that the records may be collected and analyzed for the purposes of education, quality improvement and research. I understand that any data presented in a public form (such as presentations, journals, or publications) will not include personal identifying information; the patient shall remain anonymous, unless the patient gives further consent at a later date.

I understand and agree:

I give express consent to Spring Health Corp, Get Well Clinic, Get Well Rehab, Dr. Lai and Associates, to communicate with me via electronic communications for purposes including, but not limited to: shared care, receiving reminders, announcements, and promotions for features, products, services, or other allied-health providers relating to healthcare. I understand that I can unsubscribe from such communications at any time in writing. I understand that any communications through paper, phone, fax, email, text, or video-conferencing has inherent security and privacy risks. I endeavor to engage in safe communication practices. I understand that Get Well Clinic cannot guarantee confidentiality when communicating with insecure methods (such as email). I hereby covenant and agree to release, indemnify, and save harmless Spring Health Corp, Get Well Clinic, Get Well Rehab, Associates and staff for any costs, losses, damages, liabilities, claims, actions, proceedings and all legal and other costs of any action whatsoever, from what may occur as a result of communicating through paper or electronic methods.

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