Referrals

BMC does not require a referral for services, if you would like to refer one of your patients please complete the form below:

Date of Referral(Required)

Referring Physician(Required)

Phone(Required)

Address(Required)

For which of the following are you referring for? Please note that BMC does NOT treat Chronic Pain or Stimulant Use Disorder(Required)

Alcohol Use Disorder

Opioid Use Disorder

Patient Name(Required)

D.O.B(Required)

Health Card Number(Required)

VC(Required)

Phone Number(Required)

Does your patient consent to be contacted by BMC?(Required)

If no, please have your patient contact us directly.

Yes

Current Medications(Required)

Significant psychiatric or medical problems(Required)