Referral Information

Need to send a referral? Or take the form to your doctor?

Our Certified Orthotists will spend time with each patient to assess and determine appropriate treatment plans with regard to orthotic intervention.

To refer your patient, please complete the Referral Form and submit it to Custom Orthotic Design via ONE of the three methods below:

  1. Email: Send the completed form as an attachment in an email to
  2. Fax: Print the form and fax it to (905) 828-1091
  3. Submit online: Attach the completed form through our uploader on this page

Submit Referral Form