Free ADHD Test

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Secure Physician’s Referral Portal

Precision North ADHD Clinic

info@precisionnorthadhd.ca

P: 604-606-4057

F: 604-606-4058

Precision North ADHD Assessment Referral Form

First Name

Last Name

Health No.

DOB

Sex

If Other, specify

Phone

ADHD Symptoms (select all that apply):

Inattention to details / careless mistakes Hyperactivity Not listening when spoken to directly Fails to follow instructions/finish tasks Easily distracted Engages in impulsive behaviours Fidgeting/can’t remain seated

Relevant Medical History:

Allergies:

None Yes:

Fee Disclosure

I confirm the patient understands a private fee applies for assessment.

Referring Physician Information

Physician Name

Clinic Address

Phone

Fax

Signature

Signature (typed)

Date

I confirm that I am a licensed healthcare provider in good standing with my Canadian regulatory authority.