Please select the service needed:*

Rehabilitation and Fitness:

Specified Doctor (optional):

If so, what is your main clinic?

Would you like to be contacted if this patient needs to be transferred to another GCVS department?

CLIENT/PATIENT INFORMATION

MEDICAL RECORDS, PERTINENT LAB WORK AND RADIOGRAPHS

Have radiographs been taken?*

Have medical records, lab work, and/or radiographs*

Please email, fax or send copies of radiographs with the owner.

Attach Files, Records, Data here

**Please send current lab work, biopsy reports, and medical records with this form. You may select and upload multiple files at once, or attach a single .zip file. We appreciate the opportunity to work with your patients and we look forward to supporting the relationship you have with them.