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 $ 125.00 $ 175.00 if all three
tests are ordered.
O Environmental sensitivity work-up $ 55.00
O Chemical sensitivity work-up $ 40.00
O Candida screen 1 $ 70.00 $ 120.00 if both tests
are ordered.
O Parasite screen 1 $ 80.00
O Candida screen 2 $ 50.00  
O Parasite screen 2 $ 55.00
O Dental materials compatibility test $ 120.00 $ 125.00 if both tests
are ordered
O Toxic metal detection screen $ 30.00
O Organ stress test $ 70.00  

 

 

Food Sensitivity & Candida Screen 1 & Nutritional Deficiencies   $200.00

 

Food Sensitivity & Candida Screen 1 & Nutritional Deficiencies & Hormone Imbalance   $240.00

 

 

 

 

Children's A.D.H.D. Package (Age 12 years and under) $165.00     Food Sensitivity Work-up & Neurotransmitter Deficiencies & Candida Screen 1 & Nutritional Deficiencies

O Homeopathic work-up 1 $ 55.00
O Homeopathic work-up 2 $ 75.00
O Nutritional deficiencies & Supplements test $ 55.00
O Geopathic/Electromagnetic sensitivity $ 35.00
O Virus screen $ 65.00
O Pesticides screen $ 65.00
O Enzyme Deficiencies $ 45.00
O Hormone Imbalance $ 55.00
O Children's Food Sensitivity Work-up $ 80.00
O Amino Acids Deficiencies $45.00
O Neurotransmitter Deficiencies $ 45.00

Prices do not include H.S.T.
Prices subject to change without notice.

2425 Bloor Street West, Suite 502    Toronto, Ontario   M6S 4W4   Telephone: (416) 928-6903