Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Dr. Sherif El-Maadawy MB B Ch, MSc, FRCP(C), Master-CIME, Physiatrist Dr. Brian Loewen MD, CCFP, Dip. Sport Med. Patient InformationPatient Name: *Birth Date:AddressAddress Line 1CityProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmail *GenderMaleFemalePHNDr. I. El-Gouhary MB B Ch, LMCC, CCFP, CIME Dr. O. Vicaruddin MD, PgCPain, CIME Physician Information Referring PhysicianPRACIDPhysician AddressAddress Line 1CityProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmail *FaxFamily PhysicianActive WCBActive WCBClaim Number Referral Information Fax Claim Phone Reason for referral (provide any supporting documentation):Previous history & investigations:Medications:Services RequiredIndicate specific services required:Urgent ConsultationJoint / Myofascial InjectionBack pain (Acute or Chronic)Neck pain (Acute or Chronic)Spasticity ManagementPlatelet-Rich PlasmaPsychiatryGeneral Phys. Med & Rehab ConsultPain ManagementCoordinate medications management with Chronic Pain ClinicSubmit
