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Paediatric Ambulatory Clinic

General Referral


3rd Floor West, Room 369
4001 Leslie Street, Toronto, ON M2K 1E1
http://www.nygh.on.ca
Tel: 416-756-6479
Fax: 416-756-6152
Email: paeds.clinic@nygh.on.ca


Patient Information

Last Name: *
First Name: *
Gender: *
NYGH MRN:
(if available)
Referral Date: * 6/15/2019
Address: *
City: *
Postal Code:
DOB: * Day: Month: Year:
OHIP#: *
Primary Telephone: *
Secondary Telephone:
Email:

Reason for Referral:

*

Attachments

Please attach any relevant reports or documents here:


Referring Physician/Healthcare Provider Information

Last Name: *
First Name: *
Primary Telephone: *
Fax: *
Email:
MD Billing#: *
Address: *
Consent: *