Become a Patient

Your Path to Pain Relief Starts Here

Two pathways to care: self-refer directly or have your family doctor send us a referral. Either way, our team will contact you within 24 hours.

Self-Referral

No doctor referral needed. Complete our form and we'll contact you within 24 hours.

Physician Referral

Have your family doctor fax our referral form with your medical history.

Option 1

Self-Referral Program

Our rapid-access self-referral program allows you to connect directly with our pain specialists — no physician referral required. Complete the form below and our Patient Care Coordinator will contact you within 24 hours to schedule your initial consultation.

Complete the Form

Fill in your details and describe your pain.

We Contact You

Our team reaches out within 24 hours.

Start Treatment

See your specialist and begin your care plan.

Personal Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

OHIP Number (optional)

Pain Details

Primary Pain Location *

How Long Have You Experienced This Pain? *

Previous Treatments (if any)

Service of Interest

Family Doctor (optional)

Family Doctor Name

Family Doctor Phone

Additional Notes

I consent to the Upper Room Pain Clinic collecting and using this information for the purpose of scheduling my consultation and providing medical care. I understand my information will be handled in accordance with Ontario's Personal Health Information Protection Act (PHIPA).

Option 2

Physician Referral

Family physicians, nurse practitioners, and specialists can refer patients directly to our clinic. Download the referral form below, complete it, and fax it to our office.

How It Works

Download and complete the physician referral form below.

Fax the completed form along with relevant medical records to 289-644-0255.

Our team triages the referral and contacts the patient within 48 hours.

The patient is scheduled for an initial consultation with one of our pain specialists.

Download Referral Form (PDF)Call Us: 647-910-5359

Fax Number: 289-644-0255
Please include: Patient demographics, OHIP number, relevant diagnosis, imaging reports, medication list, and reason for referral.