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# Practitioner Referral Form

## Referral Form for Clementine Natural Health

Please submit this form for referrals to the practitioners at Clementine Natural Health. We accept referrals from allied health providers, and your referrals will be prioritized for scheduling, as waitlist times may vary.

By completing this form, you confirm that you have consent from your patient to share their personal information with our clinic. We recommend documenting your patient's consent in accordance with your regulatory requirements. Once we receive this form, our staff will contact your patient directly to schedule their consultation.

Our team will provide full details of consultation and treatment costs at the time of scheduling.

For any questions, please contact us at 604.566.3345 or hello@clementineclinic.com.