This form is intended for use by the Haleo team to refer patients to Dorma. If you have any questions, please call 514.360.7753.
Instructions for Form Completion:
- Fill in all the required fields as accurately as possible.
- Submit the form once all information is completed.
Important Note:
This referral will help Dorma understand the patient’s needs and provide appropriate follow-up.
Privacy Assurance:
All patient information provided will be handled confidentially in accordance with our data protection policies.