Referral Process

Glenrose Rehabilitation Hospital

Request for Service Form

Download and print the appropriate referral form

The Request for Service form is to be filled out by the patient or family, and/or a health professional or school staff.

In addition, complete the secondary form(s) as indicated in the Request for Service forms. Send them in together to the address listed at the bottom of the Request for Service form to begin the referral process.

Secondary Forms

Once completed, forward to:

I CAN Centre for Assistive Technology
Room 38, 10230-111 Avenue,
Edmonton, Alberta
T5G 0B7

Phone: 780-735-6070
Fax: 780-735-6072