Fillable WWW.RapidAccessToMedicalSpecialists.Ca REFERRAL LETTER NON EMERGENCY (905) 897-7780

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WWW.RapidAccessToMedicalSpecialists.Ca REFERRAL LETTER NON EMERGENCY (905) 897-7780

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*DATE: _______________________ * DOB: ______________(
DD/MM/YYYY)
*LAST NAME: ________________________ *FIRST NAME: _____________________
*PHONE #: _________________________
___ EMAIL: __________________________
TO:
Reason for referral:
Patient or representative requested another opinion:
Physician request because:
*PHYSICIAN'S SIGNAT
URE:______________________________ *PHYSICIAN'S NAME: _______________________________
[
Non- emergency cases only. For Emerg. Care physician agrees to personally
Refer them to ER directly] * REFERRING PHYSICIAN OHIP #:___________________
Fax #: _________________
Simply have the patient call us at 905-897-8928 or fax this referral to 905-897-7780 with the signed referral for an appointment.
Some Specialist appointments can be booked online! Check for online booking availability by visiting www.WalkinWalkin.com/appt
For appointments, information regarding specialty clinics or any problems with this referral, please contact the clinic.
21 Queensway West, Mississauga, Ontario, L5B1B6 | For more information, visit www.RapidAccessToMedicalSpecialists.ca
WWW.RapidAccessToMedicalSpecialists.Ca
REFERRAL LETTER – NON EMERGENCY
__ALLERGY CLINIC
__CARDIOLOGY CLINIC
__ONCOLOGIST (CAN
CER)
__GASTROENTEROLOGY CLINIC
__TRAVEL MEDICINE
__INFECTIOUS DISEASES
__NEPHROLOGY CLINIC
__NEUROLOGY CLINIC
__RESPIROLOGY CLINIC
__RHEUMATOLOGY/PAIN CLINIC
__ENDOCRINE CLINIC
_
_
HEMATOLOGY CLINIC
INTERNAL MEDICINE &
SUB SPECIALTIES
PEDIATRICS &
SUB SPECIALTIES
__GENERAL PEDIATRICIAN
__PEDIATRIC
●
RESPIROLOGIST
● ALLERGY CLINIC
● CARDIOLOGIST
● DERM CLINIC
●
N
EUROLOGY CLIN
IC
WOMEN’S CLINIC &
SUB SPECIALTIES
__GYNECOLOGIST WITH COLPOSCOPY
Hormone Clinic-BCP/MAP
Irregular Periods
Infect Disease Clinic-VD/STD
PAP-test/IUD/Colposcopy
__FETAL & MATERNAL CARDIOLOGIST
SURGICAL CLINICS &
SUB SPECIALTIES
__GENERAL SURGEON
__ORTHOPEDIC
Surg __ ENT Surg
__PLASTIC
Surg __ FOOT Surg __ CHEST Surg
Skin cancer clinic
__ UROLOGY CLINIC
Prostate, ED, Urological issues etc.
__EYE CLINIC
Minor eye problems/Refracting
How Did You Find Out About Us?
Google Fax Patients Other
FAX COMPLETED REFERRALS TO
(905) 897-7780
AFFIX LABEL HERE
__GENERAL INTERNAL MEDICINE
(urgent same day
referral by walk-in)
Urgent Same Day Referral by Walk-In
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WWW.RapidAccessToMedicalSpecialists.Ca REFERRAL LETTER NON EMERGENCY (905) 897-7780

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Completed 24 June 2022

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