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.

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)
- 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 Information
Please 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) 277-1225
REMINDER - Please include patient's name on your faxes.
REVIEW & CONFIRM
PLEASE CONFIRM ALL INFORMATION ABOVE IS CORRECT*
- YES, I checked, all good to go!
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REFERRING PHYSICIAN