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Forms

For third-party requested forms or reports, an appropriate assessment fee may be charged in addition to the fee charged for completion of the form/report, when the assessment is not medically necessary.

Forms for patient use

Form Name (Download)
Travel Questionnaire (PDF)
BWFHT Ontario Patient Application for Fee Exemption (PDF)
BWFHT RAMQ Patient Application for Fee Exemption (PDF)
Application for Reimbursement (RAMQ) (PDF)
BWFHT Preventive Health Assessment (PDF)
Consent to Release Personal Health Information (PDF)
Concussion Assessment (PDF)
Nipissing District Developmental Screen (PDF)
Primary Health Care New Patient Declaration (PDF)
International prostate symptom score (PDF)
Privacy – Patient Lockbox Request (PDF)

Forms for referring providers

Form Name (Download)
Sports Medicine Referral Form (PDF)
IUC Referral Form (PDF)
Rheumatology – Musculoskeletal Ultrasound Referral Form (PDF)
Capital EMG physiatrists Referral form (PDF)
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