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FOR PHYSICIANS & REFERRING HEALTHCARE PROVIDERS

Refer a Patient to Revital Health

Physicians and referring healthcare providers can use the form below to provide patient information, requested services, and relevant clinical details.

Enter the patient’s contact information, select the preferred Revital Health clinic, and indicate the requested service. Include the diagnosis, any special instructions, and the referring provider’s details.

Please review all information for accuracy before submitting. For questions about clinic locations or service availability, call 403-815-0555.

Note: Please include the preferred clinic and accurate contact details so the receiving team can follow up if needed.
Go to Referral Form
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ADD PATIENT DETAILS

Enter the patient’s name, address, phone number, and PHN in the referral form below.

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SELECT CLINIC & SERVICE

Choose the preferred Revital Health clinic and the service or rehabilitation program requested.

Icon showing two people with a checkmark, representing completed referral information
COMPLETE REFERRAL DETAILS

Include the diagnosis, special instructions, and referring physician’s contact details and signature.

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REVIEW & SUBMIT

Check all information for accuracy, then submit the referral using the form below.