Contact Us Doctor – EmbraceSMC

Contact Us

Please submit referrals by completing the form below. Attach any relevant medical records.

Patient Name

Patient Phone Number

Alternate Contact Name

Alternate Contact Phone or Email

Patient Address

Patient Health Card

Patient DOB

Reason For Referral

Physician/ Nurse Practitioner

Billing Number

Physician/ Nurse Practioner Phone

Email Address to Confirm Receipt of Referral

Clinic Fax Number

Prefer submitting referrals offline? Download our fillable PDF form and send it via email or fax.