Referring Doctor's Name + Credential

Doctor's Office Contact Info

Email, Phone number and/or Fax

Send copy of Fitness Report to referring Doctor's Office?

Yes

Patient's Name

First Name

Last Name

Patient's Date of Birth

YYYY

Patient's Phone number

(###)

###

####

Patient's Email address

Patient's Health Information

Relevant diagnoses/diseases, health concerns

Which assessment are you ordering?

Fitness Vital Sign | $25 (Cardiovascular fitness + Grip strength)

Full assessment | $85 (Cardiovascular fitness, Grip strength, Leg Power, Balance, Lower back, Flexibility)

Location for Test

North York (4150 Chesswood Drive)

Paradise Fields (Binbrook)

Both

Thank you for referring your patient. We will contact him/her soon to schedule an appointment.