Submit a Referral

No login required. * = required field.

1Referring Physician

First Name *

Last Name *

CPSO Licence # *

Billing Number *

Office Fax * acknowledgement sent here

Office Email * acknowledgement sent here

Clinic / Practice (optional)

Office Phone (optional)

2Patient Information

Scan a patient demographics label for reference: Scan Label

First Name *

Last Name *

Date of Birth *

Phone *

OHIP Number *

Patient Email (optional)

3Referral Type

4Clinical Information

5Urgency

URGENT Call on-call
plastic surgeon

Not suitable for emergent cases.

Acknowledgement & Privacy Notice

Acknowledgement of receipt will be faxed and emailed to the contact information provided. All referrals are triaged and entered into Accuro EMR in accordance with PHIPA.

If you do not receive acknowledgement within 24 hours, call 613-591-1188 or fax to 613-591-1461.

Not monitored in real time. Not suitable for urgent/emergent requests.

Submit a Referral

Referral Submitted