EAST YORK BLOOR WEST MARKHAM HAMILTON To Richmond Hill o St. Catherines o Thornhill o Toronto o...
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Proudly Accredited by CARF HEALTH NETWORK HEALTH BOUND EAST YORK 909 Pape Ave, Suite 1 East York ON M4K 3V1 T 416-519-3775 BLOOR WEST 3250 Bloor St W, Suite 111 Toronto ON M8X 2X9 T 416-236-7778 MARKHAM 4331 14th Ave, Suite 1 Markham ON L3R 0J2 T 416-850-8558 HAMILTON 240 James St S, Hamilton ON L8P 3B3 T 416-548-7872 o o o o o Ajax o Amherstview o Barrie o Belleville o Bolton o Brampton o Branord o Burlington o Cambridge o Colborne o Dunnville o Guelph o Hagersville o Kingston o Kitchener o Milton o Mississauga o Newmarket o North York o Oakville o Orangeville o Peterborough o Richmond Hill o St. Catherines o Thornhill o Toronto o Trenton o Vaughan o Wasaga Beach o Other: PATIENT REFERRAL FORM TEL FAX EMAIL 416-548-7872 416-850-9609 [email protected] www.healthbound.ca o MVA o WSIB o EHC o SLIP & FALL o PRIVATE ASSISTIVE DEVICES / EQUIPMENT / HOME HEALTHCARE o BONE GROWTH STIMULATOR o COLD COMPRESSION THERAPY o CONTINUOUS PASSIVE MOTION DEVICE o CUSTOM MADE ORTHOPEDIC BRACES o CUSTOM MADE ORTHOTICS / SHOES o COMPRESSION HOSIERY PROGRAMS OF CARE o OUTPATIENT REHABILITATION o COMMUNITY REINTEGRATION o TRAUMA & FRACTURES o BRAIN INJURY PROGRAM o SPINAL CORD INJURY PROGRAM o HYDROTHERAPY PROGRAM o CONCUSSION PROGRAM o VESTIBULAR REHABILITATION o COGNITIVE FUNCTIONAL o CHRONIC PAIN PROGRAM DIAGNOSIS PATIENT SIGNATURE DATE o ERGONOMIC / POSITIONING DEVICES o MOBILITY DEVICES o HOME SAFETY DEVICES o HOME / VEHICLE MODIFICATION o PERSONAL CARE / HOME MAKING o NURSING / COMPANION SERVICES SERVICES / TREATMENT o PHYSIOTHERAPY o OCCUPATIONAL THERAPY o CHIROPRACTIC o ACUPUNCTURE o NATUROPATHIC o MASSAGE THERAPY / CUPPING o ACTIVE EXERCISE / PERSONAL TRAINING o CHIROPODY / FOOT CARE o MSK INJECTIONS / PRP o PSYCHOLOGICAL COUNSELING DATE OF ACCIDENT PATIENT NAME TELEPHONE ADDRESS TELEPHONE PHYSICIAN NAME I give my consent to release my personal contact and health informaon to the Health Bound Health Network for the provision of the above-menoned treatment and services.
Transcript of EAST YORK BLOOR WEST MARKHAM HAMILTON To Richmond Hill o St. Catherines o Thornhill o Toronto o...
Proudly Accreditedby CARF
H E A L T H N E T W O R K
H E A L T H B O U N D
EAST YORK909 Pape Ave, Suite 1East York ON M4K 3V1T 416-519-3775
BLOOR WEST3250 Bloor St W, Suite 111 Toronto ON M8X 2X9T 416-236-7778
MARKHAM4331 14th Ave, Suite 1Markham ON L3R 0J2T 416-850-8558
HAMILTON240 James St S,Hamilton ON L8P 3B3T 416-548-7872
o o o o
o Ajaxo Amherstviewo Barrieo Bellevilleo Boltono Bramptono Brantfordo Burlingtono Cambridgeo Colborneo Dunnvilleo Guelpho Hagersvilleo Kingstono Kitchenero Miltono Mississaugao Newmarketo North Yorko Oakvilleo Orangevilleo Peterborougho Richmond Hillo St. Catherineso Thornhillo Torontoo Trentono Vaughano Wasaga Beacho Other:
PATIENT REFERRAL FORMTELFAXEMAIL
416-548-7872416-850-9609
o MVA o WSIB o EHC o SLIP & FALL o PRIVATE
ASSISTIVE DEVICES / EQUIPMENT / HOME HEALTHCARE
o BONE GROWTH STIMULATOR
o COLD COMPRESSION THERAPY
o CONTINUOUS PASSIVE MOTION DEVICE
o CUSTOM MADE ORTHOPEDIC BRACES
o CUSTOM MADE ORTHOTICS / SHOES
o COMPRESSION HOSIERY
PROGRAMS OF CARE
o OUTPATIENT REHABILITATION
o COMMUNITY REINTEGRATION
o TRAUMA & FRACTURES
o BRAIN INJURY PROGRAM
o SPINAL CORD INJURY PROGRAM
o HYDROTHERAPY PROGRAM
o CONCUSSION PROGRAM
o VESTIBULAR REHABILITATION
o COGNITIVE FUNCTIONAL
o CHRONIC PAIN PROGRAM
DIAGNOSIS
PATIENT SIGNATURE DATE
o ERGONOMIC / POSITIONING DEVICES
o MOBILITY DEVICES
o HOME SAFETY DEVICES
o HOME / VEHICLE MODIFICATION
o PERSONAL CARE / HOME MAKING
o NURSING / COMPANION SERVICES
SERVICES / TREATMENT
o PHYSIOTHERAPY
o OCCUPATIONAL THERAPY
o CHIROPRACTIC
o ACUPUNCTURE
o NATUROPATHIC
o MASSAGE THERAPY / CUPPING
o ACTIVE EXERCISE / PERSONAL TRAINING
o CHIROPODY / FOOT CARE
o MSK INJECTIONS / PRP
o PSYCHOLOGICAL COUNSELING
DATE OF ACCIDENTPATIENT NAME
TELEPHONEADDRESS
TELEPHONEPHYSICIAN NAME
I give my consent to release my personal contact and health information to the Health Bound Health Network for the provision of the above-mentioned treatment and services.
