Atc spasticity clinic

Gait Technology Program
3560 Bathurst St., Main Floor,Toronto, ON M6A 2E1
Telephone: (416) 784-3600 Fax: (416) 784-5600
REQUEST FOR CONSULTATION
PATIENT NAME:

HEALTH CARD:
DATE OF BIRTH:
WORK/CELL:

ADDRESS:
*PLEASE ATTACH MOST RECENT MEDICAL REPORT*

REFERRING DR.:
BILLING #

ADDRESS:

TELEPHONE:

DIAGNOSIS: ____________________________________________________________________________________
CURRENT MEDICATIONS: ______________________________________________________________________________
SIGNATURE: __________________________________________ DATE: _________________________________

Able to follow instructions
Able to ambulate 25 feet with or without assistive device
Able to attend 3 times/week for 4 weeks
Ability to follow instructions, do homework and learn
Able to co-pay for a 12 session program
new skills

Please check if any of
Private Insurance
Veterans Affairs
these apply:
Then include relevant information: Case/Claim/ODSP #:
_____ pages
Contact/Case manager:

Program Stream:
Gait and Balance Training Gait Technology Program including Ness L300™ Device Assessment

*Physicians that recommend the Gait Technology Program are required to complete this form:
1- Special approval for Ness L300 Device required by Physician if patient has (please check):
2- EMG is used as a screening tool by ATC to determine candidacy for functional electrical stimulation.
NOTE: Patients with foot drop as a result of diabetic neuropathy or failed back surgery may not be candidates for FES device, but an EMG confirming eligibility may be provided at ATC.
Please Fax your referral and most recent medical report.
IMPORTANT NOTICE ON CONFIDENTIALITY:
Thank you for your referral to the ATC. The contents of this fax transmission contain confidential information intended for the person(s) named above. Any copying, disclosure or distribution
is strictly prohibited. In the event that this fax was received in error, please notify us immediately by phone and destroy this document.

Source: http://files.assistivetechnologyclinic.ca/Referral_Gait_Technology_Program.pdf