Referral Form for Health Professionals

If you are a health care professional referring a patient, please fill out this form.  This is only an initial Service Request form and thus please do not provide patient identifiers. We will follow up with you once the case has been reviewed. If you prefer, we can be reached at: 647-853-3455.

Date of Request *
Date of Request
Referring Health Professional *
Referring Health Professional
Designation *
Please indicate health profession if you indicated "Other" above.
Doctor/Clinic phone number *
Doctor/Clinic phone number
Communication preference *
How would we best reach you?
Please limit descriptors such as full name, addresses, etc.
Patient residence *
CFEMC currently services the greater Toronto area. Does the patient reside within this area?
Please provide any further pertinent information.
George Cho