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.

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. 

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. 

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).

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).

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.