| REFERRAL FORM |
RED PAW DATA
HEALTH SERVICES . |
Practitioner Information:
Clinic:
_______________________________________________________________________________
Address:
_____________________________________________________________________________
Phone: _____________________________________ Fax:
____________________________________
Do you wish the results directly sent to you? No
____ Mail ____ Fax ____
Do you wish to provide the homeopathic remedies?
Yes ____ No ____
(All our homeopathic remedies are sugar-free, alcohol-free and imprinted in spring
water.)
Signature of attending health care practitioner:
______________________________________________
Patient Information:
Name:
_______________________________________________________________________________
Address:
_____________________________________________________________________________
Phone: _____________________________________
First visit ____ Repeat visit ____
Symptoms and complaints:
______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
| Tests required: |
Cost: |
Special: |
| |
| O Food sensitivity work-up |
$ 100.00 |
$ 130.00 if all three
tests are ordered. |
| O Environmental sensitivity work-up |
$ 45.00 |
| O Chemical sensitivity work-up |
$ 35.00 |
| O Candida screen 1 |
$ 55.00 |
$ 90.00 if both tests
are ordered. |
| O Parasite screen 1 |
$ 55.00 |
| O Candida screen 2 |
$ 40.00 |
|
| O Parasite screen 2 |
$ 40.00 |
| O Dental materials compatibility test |
$ 100.00 |
$ 110.00 if both tests
are ordered |
| O Toxic metal detection screen |
$ 30.00 |
| O Organ stress test |
$ 60.00 |
Food Sensitivity & Candida Screen 1 & Nutritional Deficiencies
$155.00
Food Sensitivity & Candida Screen 1 & Nutritional Deficiencies &
Hormone Imbalance $180.00
Children's A.D.H.D. Package (Age 12 years and under) $130.00
Food Sensitivity Work-up & Neurotransmitter Deficiencies & Candida
Screen 1 & Nutritional Deficiencies |
| O Homeopathic work-up 1 |
$ 45.00 |
| O Homeopathic work-up 2 |
$ 65.00 |
| O Nutritional deficiencies & Supplements test |
$ 45.00 |
| O Geopathic/Electromagnetic sensitivity |
$ 25.00 |
| O Virus screen |
$ 45.00 |
| O Pesticides screen |
$ 45.00 |
| O Enzyme Deficiencies |
$ 35.00 |
| O Hormone Imbalance |
$ 45.00 |
| O Children's Food Sensitivity Work-up |
$ 70.00 |
| O Amino Acids Deficiencies |
$35.00 |
| O Neurotransmitter Deficiencies |
$ 30.00 |
Prices do not include G.S.T.
Prices subject to change without notice.
94
Cumberland Street, Suite 416
Toronto, Ontario M5R 1A3 Telephone: (416) 928-6903 |