Thank you for referring your patients to us. Please fill in the electronic referral form below.
If you have any questions, please call us at 1 867 336 1360

1. Date( MM/DD/YYYY) *

2. Introducing *

3. Birth Date (MM/DD/YYYY) *

4. Guardian *

5. Relationship *

6. Address *

7. City *

8. Postal codes *

9. Home phone *

10. Other phone

11. Email

12. Reason for Referral / Comments *

13. Radiographs*
NoneMeditran/Doc Servicesby Mailwith Patient


14. Primary Insurance? *
Yes (Please answer #15-#20)No (Please skip to #21)

15. Name of insured

16. Employer

17. Plan name

18. Policy no.

19. ID no.

20. % of Coverage


21. Secondary Insurance? *
Yes (Please answer #22-#27)No (Please skip to #28)

22. Name of insured

23. Employer

24. Plan name

25. Policy no.

26. ID no.

27. % of Coverage


28. Referred by *

29. Phone *

30. Appointment date *
Please contact patient for making an appointmentPatients to call to make an appointment

31. Your office is located in? * (e.g. Vancouver BC)