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Date

Please check if

URGENT: Oncology or other medically necessary fertility preservation

MFC satellite partner

CSIO

Sprout

Refer to*

First available Specialist

Dr. Meivys Garcia

Dr. Marta Wais

Dr. Crystal Chan

Dr. Salina Kanji

Dr. Daphne Chong

Referring Physician Information

Name*

First Last

OHIP Billing #*

Physician Phone Number*

Fax Number*

Email Address*

Physician Address

Street Address City Province Postal Code Country

Patient Information

Name*

First Last

Date of birth*

Gender assigned at birth*

Male

Female

OHIP (with Version Code)*

Address*

Street Address

Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred email for communication*

Patient Phone Number*

Preferred Method of Contact

Referring Information for Oncology Patients

Please attach all notes/reports. Oncology patients will be contacted within 24 hours.

Diagnosis

Check all that apply

Chemotherapy

Radiation Therapy

Surgery

Treatment completed

Please describe the reason(s) for referral*

Upload files

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Accepted file types: pdf, txt, doc, docx, html, Max. file size: 256 MB.

Please include any relevant investigations and results for the patient and partner if applicable, previous fertility testing & treatments, bloodwork results from <1 year, ultrasounds, semen analysis, genetic testing, PAP results and abdominal or pelvic surgery reports. Thank you for trusting us with your patient’s care. Markham Fertility Centre will contact your patient with the appointment date and time.

Physician Referral

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Referring Physician Information

Patient Information

Referring Information for Oncology Patients