Patient Referral Form Physician Name* Referral Clinic's Name* Patient's Full Name* Patient's Email* Phone* Patient's DOB* Health Card Number* Patient's Address* Reason for Referral* Difficulty Achieving erection? Yes No Difficulty Maintaining erection? Yes No Both Yes No Ever used PDE5i medication (Cialis/Viagara etc)? Yes No Other Other PMHx Medications: Allergies Submit Referral
