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PEDIATRIC REFERRAL/CONSULT FORM
Dream Kids Clinic & Pediatric Urgent Care
* Indicates required question
Email
*
Your email
HEALTH CARE PROVIDERS ONLY
All referrals MUST have the referring physicians OHIP registration number. Referrals must come directly from the healthcare providers office. This form will NOT be accepted if completed by parents or caregivers.
Patient Name
*
Your answer
Patient Primary Phone Number
*
Your answer
Reason For Referral/Consult
*
Your answer
Scheduling Priority Level
*
STAT: schedule in 24-96 hours - please call us after submitting this form for STAT referrals (leave voicemail if no answer)
URGENT: schedule in 1-2 weeks
NORMAL: schedule in 4-8 weeks
Referring Clinic Name
*
Your answer
Referring Physician Name
*
Your answer
OHIP Billing Number
*
Referral will not be processed without referring physician's valid OHIP billing number.
Your answer
Referring Clinic Phone Number
*
Your answer
Referring Clinic Fax Number or Email
*
Confirmation letter will be faxed or emailed, after we contact patient to schedule an appointment.
Your answer
Send me a copy of my responses.
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