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Online Referral Form

Referral Form

We provide in-person appointments for patients > 16 years of age

Patient Information

Patient Name:
Patient's E-mail:
Patient's Phone:
Patient Health Card Number:

Office / Physician Information

Referring Physician:
Office:
Office Phone #:
Office FAX #:
OHIP Billing Number:

Referral Information

* Referral criteria (and BMI cut-offs) are based on ethnicity
* Please note the different cut-offs for patients from the Middle East, South East Asia and Asian-Pacific regions

Reason for referral ( please check all that apply)

Overweight

AND

With Obesity

 

Other Information: