Self Referral Access - Releva Chronic Pain Relief Clinic

Welcome to our Self-Referral Program!

The Self-Referral Form is split into 2 parts:

Part 1: Simply provide your contact details and we will contact you soon to book your appointment

Part 2: Complete our Registration Form online to save you time from doing so in-person at your first visit (optional)

We look forward to seeing you soon!

*Please note that medications will not be offered through our Self-Referral Program – please follow up with your primary care provider with medication concerns.*

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For: Patients with Pain, chronic pain

Self-Referral Form

Fast-track your appointment without a doctor’s referral by providing us with your contact details

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For: Physicians, Nurse Practitioners

Physician Referral Form

Refer a patient with chronic non-cancer pain. There is no billing negation to FHO/FHN physicians.

Fillable PDF

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For: Physiotherapists, chiro/osteopractors

Physio Referral Form

Refer a patient with chronic non-cancer pain for interventional pain management