Refer your Patient Copy - Toronto Neurovascular Group

REFERRAL REQUEST

Thank you for your referral. All appropriate patients (including inpatient at other facilities) will be scheduled for an initial consultation at Toronto Western Hospital within 72 hours following your request.

DISCLAIMER: Please note that if you are referring an inpatient from your current facility, all transportation should be arranged by your facility. Please only send anonymized data with this request form, this server does not protect patient identity.

PATIENT INFORMATION

First Name*

Last Name*

OHIP Number*

Version Code*

PHYSICIAN INFORMATION

OHIP Billing Number*

Physician's office phone number*

Physician's office fax number*

Physician's email address*

URGENT REFERRAL

Please contact 416-603-2581 and ask to be directed to the neuro-interventional on-call.

Reason for Referral*

Brain aneurysm
Brain arteriovenous malformation (AVA) / dural fistula
Carotid stenosis
Query venous stenosis / potential stenting (Idiopathic intracranial hypertension (IIH) and / or pulsatile tinnitus
Spinal arteriovenous malformation / fistula Cavernous malformation
Other

(Please note that you will receive an answer to your request for urgent consultations, e.g. symptomatic carotid disease or large aneurysms, in 3 to 5 business days. These patient will be prioritized and seen very soon. Non-urgent referrals will be triaged accordingly.)

Other

SUPPORTING DOCUMENTS AND INFORMATION

Please fax supporting documents to 416-603-2581 or email to info@neurologytwh.com with the subject "Referral".

I confirm that I will fax or email supporting documents

Refer your Patient

Patient or Referring Physician

REFERRAL REQUEST

PATIENT INFORMATION

PHYSICIAN INFORMATION

URGENT REFERRAL

SUPPORTING DOCUMENTS AND INFORMATION

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