Booking

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Clinician(Required)

Email(Required)

Patient Name(Required)

First Last

Patient Phone(Required)

Clinic / Facility*(Required)

Thunder Bay

Dryden

Sioux Lookout

Fort Frances

Ontario Health Number(Required)

Preferred Day of Appointment(Required)

Preferred Time of Appointment(Required)

Is funding in place?(Required)

Yes

Diagnosis(Required)

Primary Concern(Required)

Comorbidities(Required)

Gait Deviation(s)(Required)

Previous Orthoses/Devices(Required)

Goals for treatment(Required)

Additional comments

Would you like us to call if we have questions before we see the patient?

Yes

Thunder
Bay
Orthopaedic