Physiotherapy Referral Form

We value all referrals and we will ensure the best quality of care for your clients. We like to make the referral process easy. To refer a client to Bergin Motion, please fill out the short form below. We will promptly follow up on the referral and start the process. You may also call us at 705-252-0330.

Referral Request Form

Referring Doctor

Client First Name

Client Last Name

DOB (YY/MM/DD)

Client Email Address

Client Phone Number

Client Address

Family Doctor

Office Phone

Details of Referral

Referral For: Referral For: Acupuncture Neurological Therapy Orthopedic Physiotherapy Pelvic Floor Physiotherapy Vestibular Physiotherapy Ultrasound Therapy Laser Therapy Motor Vehicle Injury