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 PHYSICIAN
Physician's Name*
First Last
Physician's Email
Physician Billing Number:*
Physician's Address
Street Address Address Line 2 City Province Postal Code
Physician's Phone*
Physician's Fax*
PATIENT INFORMATION
Patient's Name*
First Last
Date Of Birth*

Day
Month
Year
OHIP Number*
Version Code*
Parent or Guardian Phone Number*
Parent or Guardian Email
PROGRAM & URGENCY
Referral 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) 277-1225
REMINDER - Please include patient's name on your faxes.
REVIEW & CONFIRM
PLEASE CONFIRM ALL INFORMATION ABOVE IS CORRECT*
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Physician Referral Form

REFERRING PHYSICIAN

PATIENT INFORMATION

PROGRAM & URGENCY

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) 277-1225

REMINDER - Please include patient's name on your faxes.

REVIEW & CONFIRM

IMPORTANT: Please wait for the confirmation message before closing this window.