Haleo Request

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:

1. Fill in all the required fields as accurately as possible.
2. 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.