Referral Form

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Need to send a referral? Or take the form to your doctor?

At Thunder Bay Orthopedic, our Certfied Orthotists and Pedorthist take the time to carefully assess each patient and develop personalized treatment plans for their orthotic needs.

How to Refer a Patient
Please complete the Referral Form and submit it using one of the following options:

Email: Attach the completed referral form and send it to reception@tbortho.com
Fax: Print and fax the form to 1 (807) 345-7252
Online: Complete the form on the right and/or upload the completed referral form (PDF)

Northwestern Ontario's Orthotic and Pedorthic Professionals

Clinician Physician/HCP Name(Required)

Physician/HCP Contact (Phone or Email)(Required)

Clinic / Facility

Patient First Name(Required)

Patient Last Name(Required)

Patient Email(Required)

Patient Phone Number(Required)

Billing Number

Diagnosis/Instructions

Type of Orthotic

Custom Made Foot Orthotics

Charcot Restraint Orthotic Walker (CROW)

Ankle Foot Orthosis (AFO)

Knee Brace

Wrist Brace

Spinal

Other (please specify in Diagnosis / Instructions)

Attach Referral Form

Drop files here or

Max. file size: 20 MB.

Thunder
Bay
Orthopaedic

Referral Form

Need to send a referral? Or take the form to your doctor?

Northwestern Ontario's Orthotic and Pedorthic Professionals

Orthotic & Pedorthic Professionals

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