Requisition Forms

Welcome to Physiologix! We look forward to providing your with the highest quality comprehensive care available. We have several requisition forms to meet your individual needs.

Learn more about our Medical Specialists, Diagnostic Imaging, and Physio and Allied Health Services.

Physio & Allied Health

Please use these forms to refer to our Physio and Allied Health professionals including Physical Therapy, Massage Therapy, Acupuncture, and Psychology. Please fax referrals to 1-833-44FAXPX (1-833-443-2979). We will contact the patient directly upon receipt.

Physiotherapy Referral Form

Shockwave Referral Form

Physio & Allied Health

Please use these forms to refer to our Physio and Allied Health professionals including Physical Therapy, Massage Therapy, Acupuncture, and Psychology. Please fax referrals to 1-833-44FAXPX (1-833-443-2979). We will contact the patient directly upon receipt.

Physiotherapy Referral Form

Shockwave Referral Form

Diagnostic Imaging & Interventional Pain Management

Please use this tick-box user-friendly form to refer patients for Diagnostic Imaging services including X-ray, Ultrasound, and Pain Management. You can fax the requisition to 1-833-44FAXPX (1-833-443-2979) or have the patient call us at 1-833-4CALLPX (1-833-422-5579).

Diagnostic Imaging Requisition

All-In-One Requisition

To refer your patient to any of our services (Medical Specialists, Diagnostic Imaging, and/or Physio and Allied Health), feel free to use the All-In-One Requisition Form and fax it to 1-833-44FAXPX (1-833-443-2979).

All-In-One Requisition

Physiologix Clinic Liason

We know that in providing comprehensive services, things can get complicated for referring healthcare providers. Not sure which form to use or have a question? Clinic staff and healthcare providers, please feel free to reach out to our Clinic Liason, Ms. Rulanne Patry, via email: rulanne@physiologix.ca or cell phone: 780-977-0417 during business hours for any help.