Sleep Referrals - mHealth Online Referrals

I acknowledge the following:

This test is not funded by OHIP therefore you are required to pay $350.00 +HST to m-Health Solutions for the diagnostic test and service prior to monitoring. Once your self-referral has been received, m-Health Solutions will be in contact with you regarding next steps. Payment and shipping address must be confirmed prior to testing. This test is not funded by OHIP therefore the patient is required to pay $350.00 +HST to m-Health Solutions for the diagnostic test and service prior to monitoring. Once the requisition is received m-Health solutions will be in contact with the patient regarding next steps. Payment and shipping address must be confirmed with the patient prior to testing.

PATIENT INFORMATION

Physician you would like Results sent to*

Physician Phone*

Physician Address

Physician Unit

Physician City

Physician Province

Physician Postal Code

REASON FOR REFERRAL*

PRE-EXISTING CONDITION(S)

If you wish to receive a confirmation email that the referral was submitted successfully, please enter the email you want the confirmation to be sent to:

I wish to have the results securely emailed to the email address entered above.

Online Referral Form

Select your test:

I AM A:

I acknowledge the following:

PATIENT INFORMATION

REASON FOR REFERRAL*

PRE-EXISTING CONDITION(S)