Ontario Specialist Referrals Form

Thank you for choosing to refer your patient to Specialists on Rocket Doctor’s platform. Please note that this form will be reviewed by Rocket Doctor support staff, who will allocate it to the requested specialist. We strive to present all external referrals to specialists within 2-3 days and help specialists on the platform reply to the consultation request. If for extenuating circumstances you have not received a reply within this period of time, please email specialists@rocketdoctor.io to follow-up.

This form should only be completed by a healthcare provider.
Patient Details
Patient Name:*

Patient First NamePatient Last Name
Patient Phone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Patient Date of Birth:*

MonthDayYear
Date
Patient Health Card Number
Patient Health Card Expiry:

MonthDayYear
Date
Patient Health Card Version Code
Two letters after after health card number.
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialty requested*
If you have the details of a specific specialist provider, please provide them here (optional)
Reason for Referral:
We kindly request that you provide our specialists with sufficient clinical information to facilitate triaging and booking in a timely manner. Please include all relevant information including but not limited to reason for referral, medical history and current medications.
File Upload (optional)

Upload any files (images or documents) that are relevant to this referral
Cancelof
Referring Physician Details
Referring Provider Name:*
Provider Phone Number*
Please enter a valid phone number.
Referring Physician Fax Number:*
Referring Physician Billing Number:*
Referring Physician Email Address:
Please provide email to receive a copy of referral submission.
Signature*

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Email
example@example.com
Should be Empty:

Patient Details

Referring Physician Details