FORM “A"
Dear
Doctor:
Before
we may accept
an individual
for our in-the-home
program of rehabilitation
therapy, we must
be assured that
the person is
medically fit
and capable of
doing mild to
moderate physical
exercise.
Please
would you confirm
this information
by completing
this form and
signing it in
the appropriate
place. Please
fax the completed
form to us and
return this form
to the person
or his/her family
or guardian.
Thank
you for your kind
attention to this
matter.
Yours
truly,
A.N.D. of Canada
Patient’s
Name: _________________________________________________
Patient’s
Address: _______________________________________________
______________________________________________________________
Patient’s
Telephone Number:
_______________________________________
Doctor’s
Name: _________________________________________________
Doctor’s
Address: ________________________________________________
______________________________________________________________
Doctor’s
Telephone #:_____________________________________________
Doctor’s
Signature: _______________________________________________
Date:
__________________________________________________________
Once
this form has
been signed by
the doctor it
should be faxed
to
416-244-4099
Click
Here to download
the document.
