Physician Referral Form
This is an OHIP-covered physician-led group, consisting of eight 3-hour sessions, given once a week, on Friday afternoons, in the department of Mental Health. Treatment modalities include gentle yoga, instruction in sitting and walking meditations, the “body scan”, and group discussions about these experiences. There will be an additional 6-hour session on Sunday, in the 6th week, that participants are all expected to attend. About one hour of daily homework will be assigned. This MBSR program is suitable for people with: cancer, arthritis, headaches, irritable bowel, sleep disturbances, fibromyalgia, heart disease, high blood pressure, and other chronic medical conditions. (Exclusion criteria include substance abuse or dependence, cognitive impairment, and acute or active mental illness.) A $120.00 fee is charged for materials and uninsured medical services. For further information, please see mydoctor.ca/mbsr. If you have any patients who you believe may benefit from this program:
1) please fax your referrals to NYGH Intake at: 416-756-6671, and
* 2) patients must phone Dr. Kathy Margittai at 416-483-3778 to register.
|Patient Name | |
|Date of Birth | |
|Gender | |
|Address | |
| | |
|Home Phone | |
|Work Phone | |
|HC # | |
|List all medical conditions: | |
|Medications: | |
|Allergies: | |
| Referring MD | |
|Specialty | |
|Office Address | |
| | |
|Ref. Phone # | |
|Ref. Fax # | |
|OHIP ref.# | |
|Date of referral | Signed |
01 / 2013
-----------------------
Physician Referral Form for the
Mindfulness-Based Stress Reduction Group (MBSR) at NYGH
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- nci consent form template for adult cancer trials
- physician referral form
- cancer research poster project
- formatted for submission cancer therapy evaluation
- pet and pet ct 18f fdg oncology protocol
- i was dismayed to open this week s lake oswego review and
- outpatient consultation for radioactive iodine therapy
Related searches
- oregon home care registry and referral system
- regal medical group referral form
- special education referral form samples
- ohcc registry and referral system
- registry and referral oregon
- registry and referral log in
- dhs registry and referral system
- dhs referral line
- dhs referral form
- registry and referral system oregon
- social work referral form
- parent social work referral form