MAT Physician Referral Form

Interior Chemical Dependency Office in Kamloops via telehealth
www.icdo.ca

PRIORITY *

URGENT

ASAP

Routine

Patient First Name *

Patient Last Name *

Personal Health Care Number *

Birth Date *

Address *

City *

Postal Code *

Province *

Phone Number *

Email Address *

Relevant information *

Current medications *

Referring Physician *

MSP Number *

Physician Email Address

Thank you, your message has been sent.

There was an error trying to send your message. Please refresh this page and try again. If this error continues, please contact us by phone.