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

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Download the PDF

Patient Full Name (as stated on health card) *

Preferred Name

Patient Birth Date *

Health Card Number and Version Code *

Sex (as stated on 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 *

Preferred Pharmacy and Location *

Reason for Referral *

File Upload

Click or drag a file to this area to upload.

Download the PDF