Physician Referrals

It is important for Tripod Fertility to work in close partnership with our referring physicians. We value each patient referral and take great pride in providing a compassionate, technologically advanced environment for your patients.

Complete the Physician referral form below and click Send. Alternatively, you can download a PDF version and fax it directly to 905-471-7447 or email referrals@tripodfertility.com

We strive to provide patients with an initial consult within three weeks of the referral being received.

[contact-form-7 id="146" title="Physician Referral"]

Download the PDF

[contact-form-7 id="147" title="Patient Self-Referral"]

Download the PDF

Patient Name *

Patient Birth Date *

Health Card Number *

Sex (as stated on your health card) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Email *

Patient Phone Number *

Referring Physician Name *

Billing Number *

Physician Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physician Phone Number *

Physician Fax Number *

Reason for Referral *

File Upload

Click or drag a file to this area to upload.

Custom Captcha *

Download the PDF