Health professionals

Patient Referral for Electrotherapy

This section is for clinics wishing to refer to us patients for electrotherapy. Send us a digital version of your own form or use our online form.

Option #1

Digital file

Online Patient Referral for Electrotherapy.


Option #2

Online form

Directly enter the information on your patient referral.


Please attach a PDF, scan or photo of patient's referral form and medical prescription :

Patient’s Contact Information

Clinic’s Contact Information

Please attach patient's medical prescription :


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