To submit the form online please fill out the form below and click submit when your finished. If you do not wish to submit online, please scroll down to the Offline Self Referral section.
Offline Self Referral
Click this link: Self Referral PDF to open a pdf version that you can fill out and print. To fill out the pdf just click on the field (anything underlined) and type your answer. When you are ready to print out the document just look for your browser’s print button.(The PC’s short cut for print is press both “crtl” and “P” keys at the same time.) If you wish you may also fill the form out by hand, just open the pdf link and print it out. If you choose to not fill out the form online; please submit the completed form either through fax at 905-493-9221 or send in the form to the clinic. The clinic is located at 619 Brock St. South, Whitby, Ontario L1N 4L1.