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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.

If you wish to send a form/document to a clinic provider, please complete all patient information (including signature, if applicable) on the form/document and forward it in PDF format to records@opih.ca . The content of the email should include the first name and last initial, as well as date of birth of the individual whom the form/document pertains to. Please include the name of intended recipient (provider). Please note that fees apply for completion of forms/documents. To send a photo (picture) related to a medical issue at the request of your doctor, please click here.

Note that email communication is not a secure means of communication and that the above email addresses should not be used to communicate with your provider regarding a health issue. Patients are to call the clinic and speak to one of our staff members who can relay your message to your provider.

Forms for patient use

Form Name (Download)
Travel Questionnaire (PDF)
BWFHT 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)
Consent to Authorize Disclosure (PDF)

Forms for referring providers

Form Name (Download)
IUC Referral Form (PDF)
Capital EMG physiatrists Referral form (PDF)
Operated by Ontario Partners in Health
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