For Physicians — Trillium Neurosurgery Clinic

Patient Referrals

You can fill out the form below or email / fax your general consult form to us.

Fax: (905)228-4111 || Email: referrals@trilliumneurosurgery.com

Referring Physician Information

Date of submission:

MM

DD

YYYY

Referring Physician:

First Name

Last Name

Billing Number:

Physician Tel:

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Physician Fax:

(###)

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Patient Name:

First Name

Last Name

OHIP Number:

Patient Tel:

(###)

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Patient Email:

Reason for Consultation

Brain Tumor

Brain Aneurysm

Spinal Compression Including Disk Herniation

Pulsatile Tinnitus

Hydrocephalus

Idiopathic Intracranial Hypertension

Other

Clinical History (include pertinent investigations):

Imaging to date

MRI Scan

CT Scan

Patient Information