M D P U: E-referral

E-referral

Fill in the form below to send an e-referral.

Date of referral (mm/dd/yy) *

Patient's first and last names *

Date of birth (mm/dd/yy) *

Age *

Address *

City *

Postal code *

Telephone *

E-mail:

Health card (include version code) *

Physician's name *

Physician's billing number *

Physician's address *

Physician's city *

Physician's postal code *

Physician's telephone *

Physician's fax *

Physician's e-mail *

Reason for referral *

Working diagnosis *

Presently untreated? *

Current symptoms

Current medication(s)

Medical illnesses

Pertinent lab tests / Physician exam findings

Patient partially or fully disabled from working? *

If YES, please specify

If you prefer to print and fax this form:

Click on the icn below, print the form, complete all fields and then fax to (416) 603-5368

The following patients should not be referred to this clinic:

* Patients seeking therapy as the primary mode of treatment.
* Patients with a primary substance abuse disorder, anxiety disorder, phobias, etc.
* Patients requiring ongoing psychiatric care.

Please note:

Age limit is between 18 and 65.

Please read:

Consultation request form:
The Mood Disorders Psychopharmacology Unit welcomes the referral of patients with mood disorders (i.e. major depression, bipolar disorder). We are particularly interested in the referral of patients with newly diagnosed and untreated mood disorders. In most instances, these patients can be seen within 4 weeks of the referral date. We provide diagnostic opinions and management recommendations for mood disorder patients who are receiving treatment or who are chronically ill.