FAX: (855) 519-6611 Tel: 1 888 310-8881 ext 5430 Request-2026

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  1. Click ‘Get Form’ to open the FAX: (855) 519-6611 Tel: 1 888 310-8881 ext 5430 Request in the editor.
  2. Begin by entering the referral date in the specified format (YYYY, MM, DD). This is crucial for tracking your request.
  3. Fill in the referring physician's information, including name, specialty, address, phone, fax, email, and billing number. Ensure accuracy for seamless communication.
  4. Provide patient information such as name, address, date of birth, health card number, and gender. This section is vital for identifying the patient correctly.
  5. Select consultation options based on preference. Indicate if you prefer a specific surgeon or location to expedite your request.
  6. Complete the diagnosis and reason for referral sections by checking appropriate boxes. Include any additional requests that may assist in processing.
  7. Document past medical/surgical history and treatments to date. This information helps assess urgency and appropriateness of care.

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