Referral Form

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About
Weight Management; ALLURION Program
Pain Management; TPI
Monthly Payment
Contact

Book a consultation

Allure Medical Clinic

BOOK YOUR FREE CONSULTATION

Home
About
Weight Management; ALLURION Program
Pain Management; TPI
Monthly Payment
Contact

Add your custom HTML here

BOOK YOUR FREE CONSULTATION

Online Referral Form

Referring Physician

MSP number

Patient First Name

Patient Last Name

Date of Birth

Patient Phone

Patient Email

Weight (kg)

Height (cm)

Reason for Referral

Any history of stomach or esophageal surgery?

Pregnancy or Breastfeeding?

Thank you for the referral.

We will contact your patient as soon as possible.

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Allure Medical Clinic

Home
About
Weight Management; ALLURION Program
Pain Management; TPI
Monthly Payment
Contact

info@alluremedical.ca
www.alluremedical.ca

Copyright Allure Medical 2021

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