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 IMPORTANT: Please print a copy of our Patient Information Forms for the patient you are referring. EDP Patient Info Sheet TPWG+MD INFO SHEET 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) Medical Consult: Dr. Rachel Barrett or Dr. Samantha Martin Ongoing Medical Monitoring Eating Disorder Comprehensive Assessment Only (includes medical, psychological & dietetic) Admittance to Outpatient Eating Disorder Program (includes medical assessment, psychotherapy, dietetic support, and parental guidance) Nurse Practitioner Consultation Other Referral Reason & Other InformationPlease send via fax the following supporting documents, where applicable: • Childhood growth charts • Any investigations performed in the last year (bloodwork, ECG, imaging) • Relevant physician consultation notes (both medical and psychiatric)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