PHYSICIAN REFERRALS

Are you a physician referring a patient for an oculo-visual examination?

We've created this easy to use online referral form for you!

 

Our optometrists can often accommodate for same day or next day appointments and would be happy to send you back a report.

Patient Information

First Name*

Last Name*

Phone Number*

OHIP Number

Reason for Referral*

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Please provide your reason for referral from the drop-down menu. If reason is "ROUTINE" or "OTHER", OHIP coverage will be determined on a case-by-case basis dependent on patient age and exam findings.

Additional details

Physician Information

First Name*

Last Name*

Billing Number*

Phone Number*

Fax Number

Email

Please provide your fax number and/or email if you would like a report to be sent back to you.

* = Required field.

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