IMPORTANT:
Please complete the form below to request an appointment. One of our staff members will contact your patient within three (3) business days to confirm the appointment date and time.
This online appointment request is secure and confidential.
* Indicates required field
*Your name (referring physician)
*Your licence number
*Office phone number and email
*Briefly describe the reason for this appointment(as indicated on the referral)
*Medical specialty or clinic name for your appointment Select a Specialty Adolescent Medicine Allergy / Immunology Asthma Cleft Palate Dentistry Dermatology Dermatology – Molluscum Diabetic Endocrinology Gastroenterology (GI) General Pediatrics (Pediatric Consultation Centre – PCC) General Surgery Gynecology Infectious Diseases Neonatal Follow-up Nephrology Neurology Neurosurgery Ophthalmology Orthopedics Otolaryngology (ENT) Plastic Surgery Respiratory Medicine Rheumatology Urology
Name of doctor you wish to refer your patient to : Select a Physician
Is this your patient's first visit to The MCH ? yes no
*Is this your patient's first visit to this clinic ? yes no
*Child's last name
*Child's first name
*Date of birth Format : YYYY/MM/DD
*Age
*Health care card number
*Health care card expiration date Format : YYYY/MM
MCH Medical Record number (if known)(upper right corner of MCH red hospital card)
Address (street)
City
Province
Postal Code
*Home phone number
*Parent or guardian's last name
*Parent or guardian's first name
*Relationship to patient
*Daytime contact phone number Ext.
*Alternate contact phone number Ext.
Email address