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 Healthcard Number
*
9 digit OHIP Number
Patient OHIP Validation Code
Two Letter Code after OHIP Number
Name
First Name
Last Name
Contact Number
*
Email Address of Patient
example@example.com
Referral Confirmation Email for Provider
Must be secure email (i.e hospital). We will send a referral confirmation to this email address.
Name of Trainee Completing Form
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.
Service Referring To:
*
Cardiology
Urology
Oculoplastic Surgery
Anemia Consult by General Internist and IV Iron Infusion if necessary
Occupational Medicine
Plastic/ Dermatology
Pertinent Patient Past Medical History
Reason for Referral
*
Urgency of Referral
*
Urgent - Within 2 weeks
Routine
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