Novus Rehabilitation

Referral Form

To avoid delays, please complete as fully as possible.

If you have questions or difficulty with the completion of this form,
please contact us at 519-637-0981 or email

Client Information

Insurance Information

Workplace Benefits

Does the client have health benefits through their workplace or spouse / guardian's workplace?


If Yes:

Legal Representative Information

Referral Source Information

Thank you for choosing Novus Rehab.
We look forward to partnering with you.

Once submitted, you will receive a copy of your referral by email.

Personal information submitted to Novus is received securely and privately
and will not be shared with third parties without your permission.