Infectious Diseases Referral Form

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This form is PHIPA and PIPEDA compliant

Referring Physician First and Last Name *

Referring Physician Billing Number *

Referring Physician E-mail *

Referring Physician Phone Number *

Referring Physician Fax Number *

Referring Physician Address (including postal code)

Patient's Full Name *

Patient's Legal Sex *

Female

Male

Patient's Date of Birth *

YYYY

Patient's OHIP Number (including version code) or IFH Number *

Parent or Guardian Name(s) *

Parent or Guardian Phone Number(s) *

Parent or Guardian E-mail *

Home Address (including postal code) *

Reason for Referral *

Referral Urgency *

Routine

Semi-urgent (typically within 2 weeks, but this may not always be possible)

Urgent (please e-mail welcome@posenmd.ca to inquire on availability)

Are you attaching any documents? *

Yes, by fax at 416-491-0795

Yes, by e-mail at welcome@posenmd.ca (you must have the patient's consent to e-mail)

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