Obstetrics & Gynecology

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.

Clinics

Clinic	Services	Location	Form	Contact	Information
Obstetrical Self Referral Clinic	1. Obstetrical Care	LHSC – Victoria Hospital	Patient Handout – Contact Info	Phone: 519 685-8500 Ext. 56342	Patient to call Website
Early Pregnancy Assessment Unit (EPAU)	1. <12 weeks GA Concerns (see referral for criteria)	LHSC – Victoria Hospital	EPAU Referral	Phone: 519 685-8500 Ext. 32256 Fax: 519-663-3162	Fax Referral and Test Results / Investigations Website
Pregnancy Options Clinic – Abortion Services	1. Pregnancy Options Counselling 2. Abortion Services 3. Social Workers	LHSC – Victoria Hospital	POP Clinic Referral	Phone: 519-685-8204Fax: 519-685-8164	Fax Referral Website
Teen Pregnancy Clinic (19 and under)	1. Multi-disciplinary Teen Pregnancy Services “One-stop Shopping”	LHSC – Victoria Hospital	Generic Form	Phone:519-865-8355Fax: 519-685-8573(Attn: Teen Pregnancy Clinic)	Fax Referral OR Self ReferralFax Investigations / Antenatal Records
Colposcopy Clinic	1. Colposcopy	St. Joseph’s Healthcare Centre	Colposcopy Referral	Phone: 519 646-6100 ext. 64130Fax: 519-646-6377	Fax Referral & Test Results Website
LHSC Fertility Clinic	1. Reproductive Endocrinology and Infertility	LHSC – Victoria Hospital	LHSC Fertility Clinic	Phone: 519-663-2966 X 1 Fax: 519-663-3938	Fax Referral Website
Omega Fertility Clinic	1. Reproductive Endocrinology and Infertility 2. Early Pregnancy Assessment Clinic	107-555 Southdale Rd E London, Ontario, N6E 1A2	Omega Fertility Clinic	Phone: 519-685-5559 Fax: 519-685-5519	Fax Referral Website

London Physicians

London Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. Akhtar, Saima	1. OBGYNE	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8002 Fax: 519-685-8071	Fax consult Speaks Urdu
Dr. Abu Rafea, Basim	1. Reproductive Endocrinology and Infertility 2.Contraception	LHSC – Victoria Hospital	Generic Form	Phone: 519-663-3109 Fax: 519-663-3162	Fax consult
Dr. Black, Stephanie	1. OBGYNE 2. Contraception NOT incontinence	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8355 Fax: 519-685-8573	Fax consult
Dr. Chan, Cynthia	1. OBGYNE 2. Obstetrical Ultrasound	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8002 Fax: 519-685-8071	Fax consult
Dr. Chou, Queena	1. OBGYNE 2. Urogynecology & Pelvic Floor Repair 3. Vulva Labiaplasty	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6343 Fax: 519-646-6253	Fax consult
Dr. Crumley, Tracey	1. Obstetrics (Only)	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6401 Fax: 519-646-6010	Fax consult
Dr. de Vrijer, Barbra	1. Obstetrics (Only) 2. Maternal Fetal Medicine	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6106 Fax: 519-646-6213	Fax consult Speaks Dutch
Dr. Di Cecco, Robert	1. OBGYNE 2. Colposcopy	LHSC – Victoria Hospital	Generic Form Colposcopy Referral	Phone: 519-646-6152 Fax: 519-646-6127	Fax consult Speaks Italian
Dr. Eastabrook, Genevieve	1. Obstetrics (Only) 2. Maternal Fetal Medicine	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6106 Fax: 519-646-6213	Fax consult
Dr. Fellows, Fraser	1. OBGYNE	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6098 Fax: 519-646-6180	Fax consult
Dr. Gratton, Robert	1. Obstetrics (Only) 2. Maternal Fetal Medicine	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6106 Fax: 519-646-6213	Fax consult
Dr. King, Carol	1. OBGYNE 2. Pediatric & Adolescent Gynecology 3. Adolescent Pregnancy	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8486 Fax: 519-685-8255	Fax consult
Dr. Kirby, Joanne	1. OBGYNE 2. Minimally Invasive Surgery	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8394 Fax: 519-685-8024	Fax consult
Dr. Hardy, Ghislain	1. Obstetrics (Only) 2. Maternal Fetal Medicine	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6106 Fax: 519-646-6213	Fax consult
Dr. Hollett-Caines, Jackie	1. Infertility 2. Minimally Invasive Surgery NOT OB or Prenatal Care	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6103 Fax: 519-646-6324	Fax consult
Dr. Leong, Yvonne	1. Urogynecology	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8223 Fax: 519-685-8771	Fax consult
Dr. Lopes, Laudelino M	1. Maternal Fetal Medicine 2. Obstetric ultrasound	LHSC – Victoria Hospital Business Address 450 Central	Generic Form	Phone: 519-672-5270 ext 7051 Fax: 519-672-4459	Fax consult Contact Milly Blatnicki (London X ray Associates) Speaks Spanish and Portuguese
Dr. Lovett, Erin	1. OBGYNE	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6098 Fax: 519-646-6180	Fax consult
Dr. MacMillan, Barry	1. OBGYNE 2. Urogynecology & Pelvic Floor Repair	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6247 Fax: 519-646-6039	Fax consult
Dr. Maruncic, Michael	1. OBGYNE	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8193 Fax: 519-685-8018	Fax consult Speaks Croatian
Dr. McGee, Jacob	1. Gynecologic Oncology 2. Colposcopy	LHSC – Victoria Hospital	Generic Form Colposcopy Referral	Phone: 519-685-8500 x 55645 Fax: 519-685-8176	Fax consult
Dr. Penava, Deborah	1. OBGYNE 2. Transgender Health 3. Obesity & pregnancy	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6401 Fax: 519-646-6010	Fax consult
Dr. Prefontaine, Michel	1. Colposcopy	LHSC – Victoria Hospital	Generic Form Colposcopy Referral	Phone: 519-646-6100 x 64130 Fax: 519-646-6377	Fax consult Speaks French and Spanish
Dr. Rebel, Margaretha (Maggie)	1. Gynecology 2. Pediatric Gynecology 3. Infertility 4. Minimally Invasive Surgery NOT Obstetrical Care	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6103 Fax: 519-646-6324	Fax consult
Dr. Schmidt, Jordan	1. Obstetrics (High and Low Risk) 2. Maternal Fetal Medicine	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6106 Fax: 519-646-6213	Fax consult
Dr. Sugimoto, Akira	1. Gynecologic Oncology 2. Colposcopy	LHSC – Victoria Hospital	Generic Form Colposcopy Referral	Phone: 519-685-8500 ext 55646 Fax: 519-685-8176 519-685-8164 (Colposcopy)	Fax consult
Dr. McNaught, John	1. Infertility 2. Menopause	1695 Wonderland Rd N London, ON N6G 4W3	Generic Form	Phone: 519-439-5555 Fax: 519-286-0277	Fax consult Website
Dr. Brown, Stanley	1. OBGYNE 2. Maternal Fetal Medicine	Doctors Walk-In Medical Clinic 641 Commissioners Rd E, Unit 105 London, ON N6C 2T9	Generic Form	Phone: 519-686-8585 Fax: 519-686-8580	Fax consult

Strathroy Physicians

Strathroy Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. Chandra, Niharika	1. OBGYNE, including colposcopy	Strathroy Middlesex General Hospital	Generic Form	Phone: 519-205-2000 Fax: 519-205-2003	Fax consult Speaks French and Hindi

St. Thomas Physicians

St. Thomas Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. O’Brien, Meagan	1. OBGYNE	St Thomas Elgin General Hospital	Generic Form	Phone: 519-633-9292 Fax: 519-633-9413	Fax consult
Dr. Reddy, Natalie	1. OBGYNE	St Thomas Elgin General Hospital	Generic Form	Phone: 519-633-9292 Fax: 519-633-9413	Fax consult
Dr. Urian, Ramona	1. Gynecologic Oncology 2. Infertility 3. Urogynecology 4. Colposcopy	St Thomas Elgin General Hospital	Generic Form	Phone: 519-633-9292 Fax: 519-633-9413	Fax consult Speaks Romanian
Dr. Roe, Michael	1. OBGYNE	460 Wellington St, Suite 201 St Thomas, ON N5R 6H9	Generic Form	Phone: 519-637-3987 Fax: 519-637-3980	Fax consult

Stratford Physicians

Stratford Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. Szirmay-Kalos, Tibor	1. OBGYNE	386 Cambria St, Suite 201 Stratford, ON N5A 1J4	Generic Form	Phone: 519-272-1999 Fax: 519-272-9888	Fax consult Speaks Hungarian
Dr. Hancock, Gregg	1. OBGYNE	360 Huron St Stratford, ON N5A 5T5	Generic Form	Phone: 519-271-1912 Fax: 519-271-5772	Fax consult
Dr. Nascu, Patricia (Camelia)	1. OBGYNE NOT: urogyne, infertility	360 Huron St Stratford, ON N5A 5T5	Generic Form	Phone: 519-275-3877 Fax: 519-275-3878	Fax consult Speaks Romanian Website
Dr. Bloch, Christine	1. OBGYNE	150 Huron St Stratford, ON N5A 5S8	Generic Form	Phone: 519-273-4200 Fax: 519-273-1009	Fax consult
Dr. Hillyer, Cheryl	1. OBGYNE 2. Menopause 3. Infertility	150 Huron St Stratford, ON N5A 5S8	Generic Form	Phone: 519-271-2822 Fax: 519-271-2266	Fax consult
Dr. Wood, Jacqueline	1. OBGYNE	378 Huron St, Suite A Stratford, ON N5A 5T5	Generic Form	Phone: 519-305-0582 Fax: 519-305-0552	Fax consult

Woodstock Physicians

Woodstock Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. Pun, Jochebed	1. OBGYNE	333 Athlone Ave, Suite 106 Woodstock, ON N4V 0B8	Generic Form	Phone: 519-537-5775 Fax: 519-537-7582	Fax consult
Dr. Matanovic-Todorovic, Dragana	1. OBGYNE	333 Athlone Ave, Suite 102 Woodstock, ON N4V 0B8	Generic Form	Phone: 519-533-6962 Fax: 519-533-6963	Fax consult Speaks Serbian
Dr. Smith, Christopher	1. OBGYNE	510 Ingersoll Ave, Suite 206 Woodstock, ON N4S 4X9	Generic Form	Phone: 519-539-9211 Fax: 19-290-9311	Fax consult
Dr. Snider, Donald	1. OBGYNE	476 Peel St, 3rd Fl Woodstock, ON N4S 1K1	Generic Form	Phone: 519-533-0865 Fax: 519-533-0947	Fax consult

Goderich Physicians

Goderich Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. Moore, Julie	1. OBGYNE NOT: urogyne, infertility	Alexandra Marine and General Hospital 120 Napier St Goderich, ON N7A 1W5	Generic Form	Phone: 519-524-8323 ext 5208 Fax: 519-524-8527	Fax consult

Pediatric Physicians

Pediatric Physicians	Subspecialty / Interest	Location	Form	Contact	Information
Dr. King, Carol	1. OBGYNE 2. Pediatric & Adolescent Gynecology 3. Adolescent Pregnancy	LHSC – Victoria Hospital	Generic Form	Phone: 519-685-8486 Fax: 519-685-8255	Fax consult
Dr. Rebel, Margaretha (Maggie)	1. Gynecology 2. Pediatric Gynecology 3. Infertility 4. Minimally Invasive Surgery NOT Obstetrical Care	LHSC – Victoria Hospital	Generic Form	Phone: 519-646-6103 Fax: 519-646-6324	Fax consult

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