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AIM Clinic

Alberni Internal Medicine Clinic

Dr. Feyi Dr. Fraser Dr. Lambiotte Dr. Warbrick

AIM CLINIC
Referral Form

Dr. Kennedy Feyi Dr. Marc Lambiotte Dr. Ian Warbrick

Please note, this form is not for patient use.

CLICK HERE for a printable version of our referral form.

Referring Physician

MSP

Fax #

Physician Email

Patient Name

DOB

PHN

Phone/Cell

Patient email

Address

Referral Type

Reason for referral:

Past Medical/Surgical History:

Medications and/or allergies:

Please forward recent investigations (if available) as well as any relevant consultations.

Thank you for your referral to AIM Clinic!

Thanks for submitting!

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3831 9th Avenue

Port Alberni, BC

V9Y 4T8

Phone 778-421-8781

Fax 1-877-782-3819

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