For Patients – Neurology Centre of Toronto

Patient Request Form

Name

First Last

Phone

Email

Date of Birth

Health Card Number

Address

Street Address City Province Postal Code

Services requested

General Neurology (Requires doctor's referral)

Concussion Care Team

Occupational Therapy

Physiotherapy

Cognitive Behavioural Therapy

Nutrition

Medical-Legal Assessment

Preferred to be seen for appointment

In person

Via Teleneurology

Name of Family Doctor

Address of Family Doctor