Referral Form
For Hospital or Emergency Department referrals, our medical team will obtain pertinent health information from Connecting Ontario. No attachments necessary. You will receive email confirmation of your referral.
Patient Full Name
*
First Name
Last Name
Patient Health Card Number
*
10 digit OHIP Card Number
Patient OHIP Validation Code
Two Letter Code after OHIP Number
Date of Birth of Patient
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date of Birth
Patient's Contact Number
*
Best phone number to contact patient for booking appointment
Format: (000) 000-0000.
Patients Email Address
Patient@example.com
Name of Trainee Completing Form (If Applicable)
First Name
Last Name
Name of Staff Physician/NP for Referral
*
First Name
Last Name
Billing Number of Staff Physician/NP
*
For Residents - Please ensure to use your staff billing number.
Referring Provider Email Addresss (for referral confirmation):
Must be a secure email (i.e hospital). We will send a referral confirmation to this email address.
Referring Provider Fax Number (for referral confirmation):
Provide Fax Number (if necessary for referral confirmation)
Service Referring To:
*
Allergy and Immunology
Cardiology
Dermatology
ENT Surgery (Otolaryngology)
Anemia Consult by General Internist and IV Iron Infusion if necessary
General Internal Medicine - consultations are performed virtually. Note: we do not see fatigue NYD or urgent issues better seen by Hospital Based Internists.
Plastic Surgery
Podiatry - Ingrown Toenail for Consideration of Excision
Occupational Medicine
Oculoplastic Surgery
Sports Medicine
Travel Medicine - non OHIP
Urology
Pertinent Patient Past Medical History
Reason for Referral
*
Urgency of Referral
*
Urgent - Within 2 weeks
Routine
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