Online Referral Form - Calgary Lymphedema Rehabilitation Clinic

For general inquiries, or questions, please feel free to also just contact our clinic at lymphrehab@hotmail.com, or by phone (403) 209-6537.

Full Name: *
Daytime contact number: *
Email Address: *
Date of Birth:
Specialist (if applicable):
Has one of your physicians diagnosed Lymphedema?	Yes No
If Yes, whom?
Date of availability for assessment:
Do you give permission to contact your physician by phone and fax prior to assessment?	Yes No
Please enclose specific questions or comments?
	(* indicates a mandatory field)