Colorectal Cancer Online Referral Form

** You can submit the same information through your standard EMR
Fax: (416)756–6832/ E-mail:colorectal.navigator@nygh.on.ca


Your patient MUST be aware of this referral and will be contacted by our patient navigator. The patient navigator can be reached at
(416)756-6000 ext# 4409, (416)575-6276 or colorectal.navigator@nygh.on.ca

You can still download a PDF version and Fax it in


Patient Information:

Last Name: *
First Name: *
DOB: * Day: Month: Year:
Gender: *
HealthCard# : * Version Code: *
Address:
City:
Postal Code: -
Phone #: * ( )- -

Reason for referral * (provide additional details) :



Location of Tumor * (click all that apply)
- Please attach ALL reports with referral if available. If not, we will arrange

Diagnostic Investigations * (Click all that apply)
















Referral Request *

Preferred Surgeon: 
OR
Earliest available appointment  

Physician Information

Referring Physician Family Physician
Name: *
Billing #: *
Phone #:
Fax #:

*