Physician Referrals

Physician Referrals

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

Simply complete the Physician referral form below and click Send. Alternatively, you can download a PDF version and fax directly to 905-471-7447. We strive to provide patients with an initial consult within three weeks of the referral being received.

Download the PDF

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 Code *

Physician Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physician Phone Number *

Physician Fax Number *

Reason for Referral *

Download the PDF