Physician Referral - Bloor Kids

Please have a physician complete the physician referral form below
and fax to (647) 480-0909

Once the referral is received, our staff will review it and will respond
to the referral request.

Physician's First Name *

Physician's Last Name *

Physician's Email *

Physician Billing Number: *

Physician's Address

City

Province

Postal Code

Physician's Phone *

Physician's Fax *

Child's First Name *

Child's Last Name *

Gender at Birth *

Date of Birth *

OHIP Number *

Version Code

Parent or Guardian Name(s) *

Parent or Guardian Phone Number *

Parent or Guardian Email

Address

Referral To: (select all that apply)

Referral Urgency

Urgent, 1-2 DaysSemi-Urgent, 1-2 WeeksNot Urgent

Referral Reason & Other Information

0 of 1000 max characters

Please fax additional documents to 647.480.0909

REMINDER - Please include child's name on your faxes.

Please confirm all information above is correct *

YES, I checked, all good to go!

* Required field