Physician Referral Form A copy of this form will also be emailed to you, the referring physician, should you wish. Our FAX number is: (647) 277-1225 REFERRING PHYSICIANPhysician's Name* First Last Physician's Email Physician Billing Number:* Physician's Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Physician's Phone*Physician's Fax*PATIENT INFORMATIONPatient's Name* First Last Date Of Birth* Day Month Year OHIP Number* Version Code* Parent or Guardian Phone Number*Parent or Guardian Email PROGRAM & URGENCYReferral To: (select all that apply) Pediatric/Adolescent Medicine consult and follow-up if needed: Dr. Rachel Barrett or Dr. Samantha Martin Nurse Practitioner Consultation Referral Reason and Other Information - please provide as much detail as possible:*Has your patient received any Eating Disorder or mental health diagnoses, and if so, when and from whom?*Has your patient ever been hospitalized as a result of their eating-related concerns? If so, please include program details, approximate dates, and any ongoing ED-related care they're receiving:*Please send via fax the following supporting documents needed in order to process your referral: • Childhood growth charts. • Any investigations performed in the last year (bloodwork, ECG, imaging). • Relevant physician consultation notes (both medical and psychiatric). • Hospitalization consult and discharge notes. PLEASE FAX ADDITIONAL DOCUMENTS TO (647) 277-1225REMINDER - Please include patient's name on your faxes.REVIEW & CONFIRMPLEASE CONFIRM ALL INFORMATION ABOVE IS CORRECT* YES, I checked, all good to go! IMPORTANT: Please wait for the confirmation message before closing this window.CAPTCHA