ORANGEVILLE PATIENT REFERRAL FORM
MBI - MINDFULNESS-BASED INTERVENTION PROGRAMS
Facilitated by Dr. Kim R. McKenzie, MD (FRCP)
Please print this document and have your doctor fill out the “Physician’s Details” section
In order to ensure your time making this referral is worthwhile, please complete the following form:
The patient referred knows that the classes are 2.5 hours
per week over a 13-week period, in a group setting, and that
attendance for all classes is recommended.
The patient understands that the course involves
practicing guided meditation and reading course material, at
home between classes.
PATIENT FIRST NAME:
The patient is aware that OHIP covers the
majority of the course costs but there is an
additional for Course Materials and Enrolment for
the MBI Chronic Pain Management. (MBCPM™)
PATIENT LAST NAME:
HEALTH CARD NO.
VC
EXPIRY DATE
ADDRESS:
DOB (D/M/Y)
CITY
POSTAL CODE
PROV.
EMAIL
CONTACT #:
OTHER PHONE #
PHYSICIAN’S DETAILS - Please have your doctor fill out this section.
Physician’s Name
OHIP Billing No.
OFFICE ADDRESS:
CITY
PROV.
POSTAL CODE
PHONE #:
EMAIL
EXT.
FAX
Family Physician (if different than above)
REASON FOR REFERRAL:
Date of Request ..................................Referring Physician’s Signature X _____________________________
PLEASE SEND REFERRAL FAX TO:
705-327-9181 - Attn. Sheri-Leigh