All referral forms on this website are also available as eForms for OSCAR, Avaros, Indivicare, and ACCURO EMRs. You can download some of the premade forms here from WorldEMR or fill the contact form below for any other eForms that are not listed for your EMR.
Table of Contents
Clinics
| Clinic | Services | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Urgent TIA Clinic | 1. TIA & Stroke Prevention | LHSC – University Hospital | TIA Clinic ReferralTIA Clinic Patient Handout | Phone: 519-663-3674 Fax:519-663-3140 | Fax Consult & Investigations |
| Urgent TIA Clinic (Stratford) | 1. TIA & Stroke Prevention | Stratford General Hospital – West Building, Level 2 | Stratford TIA Clinic Referral | Phone: 519-272-8210 x 2299 Fax: 519-272-8242 | Fax Consult & Investigations |
| Urgent TIA Clinic (St. Thomas Elgin) | 1. TIA & Stroke Prevention | St Thomas Elgin General Hospital | St. Thomas TIA Clinic ReferralSt. Thomas TIA Clinic Patient Handout | Phone: 519-631-2030 x 2125 Fax: 519-637-3097 | Fax Consult & Investigations |
| Urgent Neurology Clinic | 1. TIA & Stroke Prevention | LHSC – Victoria Hospital Hospital (Zone E Floor 5) | Urgent Neurology Referral | Phone: 519- 667-6661 Fax: 519-667-6766 | Fax Consult & Investigations |
| EMG & Nerve Conduction Testing | 1. EMG Laboratory | LHSC – University Hospital | EMG ReferralEMG Lab Patient Pamphlet | Phone: 519-663-3665 Fax: 519-663-3592 | Fax Consult |
| Pediatric Neurology Clinic | 1. Pediatric Neurology | Children’s Hospital London Health Sciences Centre | Pediatric Neurology Referral | Phone: 519-685-8332 Fax: 519-685-8350 | Fax Consult & InvestigationsWebsite |
| Pediatric Headache Clinic | 1. Pediatric Headache Management | Children’s Hospital London Health Sciences Centre | Pediatric Headache Clinic Referral | Phone: 519-685-8332 x 2 Fax: 519-685-8350 | Fax Consult & InvestigationsWebsite |
London Physicians
| London Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Gibson, Andrew | 1. Neurology | Forest City Neurology Clinic 6 – 627 Maitland Street London, Ontario N5Y 2V7 | Generic Form | Phone: 226-721-8800 Fax: 519-963-0588 | Fax consult |
| Dr. Ciftci, Beyza | Neurology-Multiple Sclerosis **ONLY** | LHSC – University Hospital | Generic Form | Phone: 519-663-3430 Fax: 519-663-3423 | Fax consult |
| Dr. Riccio, Patricia | Neurology-Multiple Sclerosis **ONLY** | LHSC – University Hospital | Generic Form | Phone: 519-663-3259 Fax: 519-663-3265 | Fax consult |
| Dr. Berger, Warren | 1. Multiple Sclerosis 2. Botox Treatments **ONLY** | Forest City Neurology Clinic 6 – 627 Maitland Street London, Ontario N5Y 2V7 | Generic Form | Phone: 226-721-8800 Fax: 519-963-0588 | Fax consult |
| Dr. Kay, John | 1. Neurology 2. Migraines / Headaches 3. Parkinson’s Disease 4. Multiple Sclerosis 5. Movement Disorders | 190 Wortley Rd, Suite 209 London, ON N6C 4Y7 | Generic Form | Phone: 519-667-2221 Fax: 519-667-2001 | Fax consult |
| Dr. Maloney, Michelle | 1. Neurology | 151 Pine Valley Boulevard, Unit 5 London, ON N6K 3T6 | Generic Form | Phone: 519-680-0003 Fax: 1-855-351-9207 | Fax consult |
| Dr. Mailo, Janette | 1. Neurology 2. Pediatric Neurology | Nixon Medical Centre South London 510 Southdale Road East Suite 301 London ON N6E 0B2 | Generic Form | Phone: 519-690-2806 Fax: 519-690-2809 | Fax consult |
| Dr. Mendonca, Daniel | 1. Neurology 2. Parkinson’s Disease 3. EMG | 450 Central Avenue Suite 401 London ON N6B 2E8 | Generic Form | Phone: 519-601-7100 Fax: 519-601-6525 | Fax consult |
| Dr. Melinyshyn, Alexander | 1. Neurology 2. Migraines / Headaches | 1055 Fanshawe Park Rd W, Suite 302, London ON N6G 5B4 | Generic Form | Phone: 226-213-7171 Fax: 519-933-4458 | Fax consult |
| Dr. Yu, Yeyao | 1. Neurology | Thompson Medical Centre 130 Thompson Rd London ON N5Z 2Y6 | Generic Form | Phone: 519-601-8621 Fax: 519-204-3122 | Fax consult |
| Dr. Burneo, Jorge | 1. Neurology 2. Epilepsy | LHSC – University Hospital | Generic Form | Phone: 519-663-3464 Fax: 519-663-3498 | Fax consult |
| Dr. Chan, Richard | 1. Neurology 2. Stroke | LHSC – University Hospital | Generic Form | Phone: 519-663-3292 Fax: 519-663-3294 | Fax consult |
| Dr. Cooper, Paul | 1. Headache & Migraine only | LHSC – University Hospital | Kreeft Headache Clinic | Phone: 519-663-2906 Fax: 519-663-2933 | Fax consult |
| Dr. Debicki, Derek | 1. Neurology 2. Epilepsy | LHSC – University Hospital | Generic Form | Phone: 519-663-3229 Fax: 519-663-3237 | Fax consult |
| Dr. Diosy, David | 1. Neurology 2. Epilepsy | LHSC – University Hospital | Generic Form | Phone: 519-663-3248 Fax: 519-663-3152 | Fax consult |
| Dr. Finger, Elizabeth | 1. Frontotemporal Dementia and related disorders | Parkwood Hospital | Generic Form | Phone: 519-646-6032 Fax: 519-646-6032 | Fax consult |
| Dr. Florendo-Cumbermack, Anita | 1. Neurology 2. Neuromuscular Disorders | LHSC – University Hospital | Generic Form | Phone: 519-663-3129 Fax: 519-663-3107 | Fax consult |
| Dr. Fraser, Alex | 1. Neurology 2. Neuro-ophthalmology | LHSC – University Hospital | Generic Form | Phone: 519-663-3702 Fax: 519-663-3999 | Fax consult |
| Dr. Gofton, Teneille | 1. Neurology 2. Palliative Care Neurology | LHSC – University Hospital | Generic Form | Phone: 519-663-2911 Fax: 519-663-3152 | Fax consult |
| Dr. Hachinski, Vladimir | 1. Urgent TIA Clinic Only | LHSC – University Hospital | Urgent TIA Clinic | Phone: 519-685-8500 x33674 Fax: 519-663-3140 | Fax consult |
| Dr. Jenkins, Mary | 1. Movement Disorders Only | LHSC – University Hospital | Generic Form | Phone: 519-663-3404 Fax: 519-663-3416 | Fax consult |
| Dr. Jog, Mandar | 1. Movement Disorders Only | LHSC – University Hospital | Generic Form | Phone: 519-663-3814 Fax: 519-663-3174 | Fax consult |
| Dr. Khaw, Alexander | 1. Neurovascular & Stroke & TIA Consults Only | LHSC – University Hospital | Generic Form | Phone: 519-685-8500 ext 32944 Fax: 519-663-3411 | Fax consult Speaks German |
| Dr. MacDonald, Maria | 1. Brain Tumours 2. Peripheral Nerve Dysfunction | London Health Sciences Centre – London Regional Cancer Program | LRCP Referral | Phone: 519-685-8640 Fax: 519-685-8624 | Fax consult |
| Dr. MacDonald, Penny | 1. Movement Disorders 2. Parkinson’s Disease | LHSC – University Hospital | Generic Form | Phone: 519-663-3631 Fax: 519-663-3753 | Fax consult |
| Dr. Mandzia, Jennifer | 1. Neurovascular & Stroke & TIA Consults Only | LHSC – University Hospital | Urgent TIA Clinic | Phone: 519-663-2944 Fax: 519-663-3411 | Fax consult |
| Dr. Markovic, Nevena | 1. Neurology | LHSC – University Hospital | Generic Form | Phone: 519-685-8500 x32961 Fax: 519-663-3601 | Fax consult |
| Dr. McLachlan, Richard | 1. Neurology 2. Epilepsy | LHSC – University Hospital | Generic Form | Phone: 519-663-3293 Fax: 519-663-3294 | Fax consult |
| Dr. Moulin, Dwight | 1. Neuro-Oncology 2. Cancer & Neuropathic Pain | London Health Sciences Centre – London Regional Cancer Program | LRCP Referral | Phone: 519-685-8661 Fax: 519-685-8636 | Fax consult |
| Dr. Nicolle, Michael | 1. Neuromuscular Disease 2. Neuromuscular Transmission Disorders (Myesthenia Gravis, Lambert-Eaton) *No General Neurology | LHSC – University Hospital | Generic Form | Phone: 519-663-3236 Fax: 519-663-3328 | Fax consult |
| Dr. Pasternak, Stephen | 1. Cognitive Impairment Diseases Only | Parkwood Hospital | Generic Form | Phone: 519-646-6032 Fax: 519-646-6226 | Fax consult |
| Dr. Shoesmith, Christen | 1. Neuromuscular Disease 2. Amyotrophic Lateral Sclerosis 3. Neurology During Pregnancy | LHSC – University Hospital | Generic Form | Phone: 519-663-3597 Fax: 519-663-3609 | Fax consult |
| Dr. Sposato, Luciano | 1. Neurology 2.Stroke & TIA | LHSC – University Hospital | Generic Form | Phone: 519-663-3110 Fax: 519-663-3473 | Fax consult |
| Dr. Strong, Michael | 1. Motor Neuron Diseases (ALS) | LHSC – University Hospital | Generic Form | Phone: 519-663-3874 Fax: 519-663-3609 | Fax consult |
| Dr. Watling, Christopher | 1. Neuro-Oncology ONLY | London Health Sciences Centre – London Regional Cancer Program | LRCP Referral | Phone: 519-685-8602 Fax: 1-888-356-8889 | Fax consult |
Pediatric Physicians
| Pediatric Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Andrade, Andrea | 1. Pediatric Neurology 2. Epilepsy | Children’s Hospital London Health Sciences Centre | Pediatric Neurology Referral | Phone: 519-685-8332 Fax: 519-685-8350 | Fax consult |
| Dr. Campbell, Craig | 1. Pediatric Neurology 2. EMG 3. Neuromuscular Disorders | Children’s Hospital London Health Sciences Centre | Pediatric Neurology Referral | Phone: 519-685-8332 Fax: 519-685-8350 | Fax consult |
| Dr. Mailo, Janette | 1. Pediatric Neurology 2. Neurology | Children’s Hospital London Health Sciences Centre | Pediatric Neurology Referral | Phone: 519-685-8332 Fax: 519-685-8350 | Fax consult |
| Dr. Prasad, Asuri | 1. Pediatric Neurology 2. Epilepsy | Children’s Hospital London Health Sciences Centre | Pediatric Neurology Referral | Phone: 519-685-8332 Fax: 519-685-8350 | Fax consult |
Community Resources
| Community Resource | Services | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Clinic to Community | 1. Adult & Peds Epilepsy Support 2. Case Management 3. Seizure First Aid 4. Free & Offered in Pt Community | 797 York St, Unit 3, London, ON N5W 6A8 | Clinic to Community Epilepsy Referral | Phone: 519-433-4073 Fax: 519-433-4079 | Fax Referral Website |
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