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REFER NOW
Online Referral Form
(For Referring MD’s ONLY)
Choose Location
Select one...
Oakville/Milton
Burlington
Mississauga
Cambridge
Kitchener
London
First Name
(patient)
Last Name
(patient)
Health Card number
VC
Date of Birth
(patient)
Contact Phone Number
(patient)
Email Address
(Patient)
Request for
Select one...
Sleep Study AND Consultation
Sleep Study ONLY
Consultation ONLY
REASON FOR REFERRAL
(Select A Minimum Of TWO Symptoms)
Snoring
Insomnia
Suspected OSA
Restless Legs
Excessive Daytime Sleepiness
Narcolepsy
Abnormal Sleep Behavior
Has this patient had a previous sleep study performed anywhere in Ontario?
(Check one)
Yes
No
If YES, please specify date & location last sleep study:
REFERRING PHYSICIAN
Please enter your full name. By entering your Full Name here you attest that you, the referring physician are signing this referral in an electronic submission.
Full Name
Phone Number
(Physician)
Fax Number
(Physician)
OHIP Billing Number
Is the patient currently on Oxygen?
(Check one)
Yes
No
Does the patient have any Allergies?
(Check one)
Yes
No
Does the patient have Special Needs?
(Check All That Apply)
Language Barrier
Requires an Attendant
Ambulation Restricted / Wheelchair
Additional Comments & Requirements
Attach Additional Documents
If any documents (eg: patient profile, medication history) accompany this referral, please press the “Attach Additional Documents” button to send accompanying documents via e-mail.
Return to this page once completed to click the blue “Submit” form and you will receive a green message stating your referral has been received
.
Thank you!
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