Neurology Referral

Use this online form to refer a patient to Dr. Danah Bohemid at Heart and Health Clinic for Neurology.

Alternatively, you can refer patients to us through the Ocean Referral System or by downloading and sending the referral form by email or fax.

Central Booking Line

T: (289) 760-9550
F: (905) 296-3858
E: clinic@heartandhealth.ca

Our Clinic Locations

Reason for Referral

MEDICAL HISTORY

  1. Past medical history
  2. Medication list
  3. Test results completed within last 12 months (including MRI, EEG, NCS/EMG, etc.)
  4. Relevant consultation reports (e.g. Neugology, Geriatrics, etc.)

Type your first and last name below to act as your e-signature for the purpose of this referral.