1. No category

7600 Weston Road, Unit 55
Woodbridge, ON
L4L 8B7
Phone: (289) 371-3500
Toll-Free: 1 (855) 371-3500
Fax: (289) 371-3399
REFERRAL FORM
Patient name: ________________________________
Date of Birth: ________________________________
Home phone: ________________________________
Cell phone: __________________________________
Health Card #: ________________________________
[email protected]
□
Please
check all consultation
and or diagnostic services requested:
DERMATOLOGY
□
CARDIOLOGY
Dr. Faisal Al-Mohammedi, MD, FRCPC & Associates
Dr. Sudip Datta, FRCPC, FACC
□ Cardiology Consultation (ECG, ECHO, STRESS TEST)
□ STRESS □ ECHO □ ECG
□ Loop/Event Recorder (14 days)
□ Holter Monitor □ 48hr
□ Ambulatory Blood Pressure Monitor □24hr □48hr (Non-OHIP)
PSYCHIATRY
□
Dr. Joelle Fareau-Weyl, MD, FRCPC
INTERNAL MEDICINE
□
Dr. Poli Lekas, MD, FRCP(C) & Dr. Clive Sinoff, MD, FRCP(C)
□ Hypertension
□ Heart Failure
□ Diabetes
□ Chronic Kidney Disease (Dr. Lekas - Nephrologist)
□ Other (specify): __________________________________
□
GYNECOLOGY
□
□
Sameer Sekhon, D. Podiatric Medicine (Reg. Chiropodist)
Dr. Eric Grief, MD, CCFP
PSYCHOTHERAPY & ANXIETY COUNSELING
□
Dr. Monica Narula, MB, BCh, BAO, CCFP (GP)
FOOT PAIN – ORTHOTICS
DIABETIC FOOT CARE
Dr. Bernard Greisman, MD, FRCPC
MEDICALLY-SUPERVISED WEIGHT LOSS
□
MEDICAL COSMETIC PRACTICE
CHIROPRACTIC – ACUPUNCTURE (non-OHIP)
□
Amy Yee, DC
Dr. Eric Grief, MD, CCFP
Reason for Referral (required):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name of Referring MD: ________________________________ Signature of referring MD: ________________________
Referring MD billing #: _______________________
Our office will contact the patient to make an appointment date
Date of Referral: ________________________________
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Please attach all relevant imaging, blood work and or consults.