Fax Referral Form | braxia-health

Braxia Health Fax Referral Form

Typed referrals are preferred. If hand-written, please ensure the writing is legible or we will be unable to process the referral.
We will only accept a fully completed form.
Please ensure that the patient’s health card is up to date.
Please ensure that the patient meets the clinic’s inclusion/exclusion criteria.

I acknowledge the above policies and will complete the form fully.

Access is restricted to licensed healthcare providers only. Please confirm your status to continue.