Practitioner Referrals

Wise Elephant Family Health Team offers a variety of specialty services, including but not limited to:

  • Palliative Care Home Services
  • Chronic Care Home Services
  • Wise Travel Clinic

As a health practitioner you can refer your patients to Wise Elephant Family Health Team’s extended services. Once the form is completed we will review your submission and contact the patient to make further arrangements.

 

Submit Referrals

Referred By:

Referral Email:

Agency/Practice:

Agency/Practice Phone:


Patient's Full Name:

Patient's Email:

Patient's Phone:


Department/Service Required:

Reason for Referral:


By submitting this form I am consenting to the Wise Elephant Family Health Team contacting the above listed patient at my request. The patient listed above has been notified that Wise Elephant Family Health Team will be contacting them.

This referral form is for health professionals only – if you are a patient interested in obtaining a new family doctor through Wise Elephant FHT, please do not submit this form. Complete the Patient Intake form on our home page instead.

If you have a general inquiry, please visit our contact page and complete the form there.