AREP Referral Form

Arthritis Rehabilitation and Education Program (AREP) provides a range of services for children and adults with arthritis, at no cost to clients who reside in Ontario as a service funded by Ontario Health.

Client Eligibility Requirements: - Diagnosis of arthritis where arthritis must be the primary presenting problem (note: we do not see patients for post-operative care), and a valid Ontario Health Card Number.

Please complete the form and we will call you to book an appointment. The Arthritis Society is committed to protecting any personal health information collected, used and disclosed by the Arthritis Rehabilitation and Education Program, as required by the Personal Health Information and Protection Act and guidelines from the Information and Privacy Commission of Ontario.

Type of Referral:

Self Referral Health Care Professional

If you are a Health Care Professional, please provide the following:

Name and Designation:

Address:

Phone Number:

Fax Number:

Email:

Agency:

Client Information

Client First Name:

Preferred Name:

Last Name:

Gender:

If Other, please self identify:

Home Phone#:

Cell Phone#:

Work Phone#:

Preferred Contact Phone:

Home Cell Work

Address:

City:

Province:

Postal Code:

Date of Birth:

Ontario Health Card Number (no dashes):

Ontario HCN Version code (if applicable):

AREP provides automated email reminders prior to appointments. By providing your email address, you consent that we can use this email to contact you about your appointment, send reminders and send items related to your appointment (e.g. assessment forms, client experience survey).

Email:

Preferred Language for Service:

English French

Language Spoken at Home:

English French Other

If Other, please specify:

If the client is under the age of 16, please provide parent or (legal) guardian information.

First Name:

Last Name:

Relationship to client:

Preferred Phone number of parent or legal Guardian:

Additional Information

What type of arthritis brings you to us? (Choose primary diagnosis)

If Other, please specify:

Has the diagnosis been confirmed or is it suspected?

Yes Confirmed No Suspected

When were you diagnosed:

What is the reason you would like to see one of our clinicians?

If Other, please specify:

How did you hear about AREP services?

Arthritis Society Website Facebook Health Care Provider Family/Friends Other

If Other, please specify: