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.
Fetal Risk Assessment from Maternal Exposure (FRAME) Program
| Location | Form | Contact | Information | |
| Safety of Medications in Pregnancy and Breastfeeding clinic | 800 Commissioners Rd E London, ON N6A 5W9 | Any referral form works FRAME Fax Referral Form Generic Form | Phone: 519-685-8500 ext 58293 Fax: 519-685-8156 Email: [email protected] | Website Fax consult |
Table of Contents
First Five Young Children’s Wellness Clinic
| Location | Form | Contact | Information | |
|---|---|---|---|---|
| West Elgin Community Health Centre First Five West Program Must Read Brochure | Clinic locations in West Lorne & St. Thomas | First Five West Program Referral Form | Phone: 519-768-1715 ext 2301 Fax: 519-768-2548 | Website Fax consult or patient self-refer |
London
| London | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Al-Qadhi, Samim | 1. Pediatrics | Thompson Medical Centre 130 Thompson Road London, Ontario N5Z 2Y6 Lucan Medical Centre 268 Main St P.O Box 310 Lucan ON N0M 2J0 | Generic Form | Phone: London: 519-601-8621 ext 221 Phone Lucan: 519-227-1163 Fax: London: 519-204-3122 Fax Lucan: 519-227-1558 | Fax consult Speaks Arabic |
| Dr. Danby, Michelle | 1. Pediatrics | 499 Oxford St E London, ON N5Y 3H8 | Generic Form | Phone: 226-289-3628 Fax: 226-298-2345 | Fax consult |
| Dr. Gloor, Jane | 1. Pediatrics | Springbank Medical Centre 460 Springbank Dr, Suite 206 London, ON N6J 0A8 | Generic Form | Phone: 519-641-8687 Fax: 519-641-6518 | Fax consult Website |
| Dr. Gorodzinsky, Fabian | 1. Pediatrics 2. Behavioural Problems 3. Learning Disabilities | 610 Colborne St London, ON N6B 2V2 | Generic Form | Phone: 519-672-4051 Fax: 519-672-4394 | Fax consult |
| Dr. Jakobczyk, Jessica | 1. Pediatrics 2. Pediatric Headaches | Nixon Medical Centre 510 Southdale Rd E, Suite 301 London, ON N6E 0B2 | Generic Form | Phone: 519-690-2806 Fax: 519-690-0970 | Fax consult |
| Dr. McNeely, Michael | 1. Pediatric Dermatology | 272 Oxford St W London, ON N6H 1S9 | Generic Form | Phone: 519-434-1112 Fax: 519-434-7950 | Fax consult |
| Dr. Mohammed, Afzal | 1. Pediatrics | Nixon Medical Centre – South London Children\’s After Hours Clinic 510 Southdale Rd E, Suite 310 London, ON N6E 0B2 | Generic Form | Phone: 519-690-2806 ext 1 Fax: 519-690-2807 | Fax consult |
| Dr. Mohammed, Javed | 1. Pediatric Dermatology | 510 Southdale Road East Suite 301 London ON N6E 0B2 | Generic Form | Phone: 519-690-2806 Fax: 519-690-2809 | Fax consult |
| Dr. Nagar, Rohit | 1. Pediatrics | 510 Southdale Road East Suite 301 London ON N6E 0B2 | Generic Form | Phone: 519-690-2806 ext 2 Fax: 519-672-7888 | Fax consult |
| Dr. Nanda, Sunit | 1. Pediatrics 2. Behavioural Disorders | 185 Commissioners Rd W London, ON N6J 1X9 | Generic Form | Phone: 519-438-3296 Fax: 519-438-2912 | Fax consult |
| Dr. Nasreen, Ruksana | 1. Pediatrics | Children\’s After Hours Clinic 1653 Richmond St London, ON N6G 2M9 | Generic Form | Phone: 519-850-3800 Fax: 519-850-5099 | Fax consult Speaks Bengali Website |
| Dr. Pavri, Daisy | 1. Pediatrics | 301 Wellington Rd London, ON N6C 4P1 | Generic Form | Phone: 519-673-6672 Fax: 519-673-6669 | Fax consult Speaks Gujarati & Hindi |
| Dr. Ramadan, Said | 1. Pediatrics | 611 Wonderland Rd N London, ON N6H 4V6 | Generic Form | Phone: 519-471-6686 ext 295 Fax: 519-471-2801 | Fax consult Speaks Arabic |
| Dr. Rouhani, Nassim | 1. Pediatrics 2. Behaviour Disorders (ADHD) | 524 Oxford St E London, ON N5Y 3H7 | Generic Form | Phone: 519-601-6601 Fax: 519-601-6603 | Fax consult Website |
| Dr. Sethna, Mia | 1. Pediatrics | Thompson Medical Centre 130 Thompson Road London, Ontario N5Z 2Y6 | Generic Form | Phone: 519-601-8621 Fax: 519-204-3122 | Fax consult |
| Dr. Sottosanti, Maria | 1. Pediatrics 2. Pediatric Endocrinology | 510 Southdale Road East Suite 301 London ON N6E 0B2 | Generic Form | Phone: 519-690-2806 ext 5 Fax: 519-690-0970 | Fax consult |
| Dr. Stare, Liga | 1. Pediatrics | Springbank Medical Centre 460 Springbank Dr, Suite 206 London, ON N6J 0A8 | Generic Form | Phone: 519-641-8687 Fax: 519-641-6518 | Fax consult Speaks Latvian Website |
| Dr. Hashi, Ifrah | 1. Pediatrics | Proudfoot Medical Clinic 524 Oxford St W #4 London, ON N6H 1T5 | Dr. Hashi Referral Letter | Phone: 519-473-5454 Fax: 519-474-0765 | Fax consult |
Regional
| Regional | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Ahmed, Syed | 1. Pediatrics | Elgin Paediatric Group 426 Talbot St, Suite 103 St Thomas, ON N5P 1B9 | Generic Form | Phone: 519-637-8074 Fax: 519-637-2646 | Fax consult Speaks Hindi, Kashmiri, Urdu |
| Dr. Bertoldi, Margaret | 1. Pediatrics | 426 Talbot St, Suite 11 St Thomas, ON N5P 1B9 | Generic Form | Phone: 519-637-0009 Fax: 519-637-5799 | Fax consult |
| Dr. Hussain, Asmaa | 1. Pediatrics | Elgin Paediatric Group 426 Talbot St, Suite 103 St Thomas, ON N5P 1B9 | Generic Form | Phone: 519-637-8074 Fax: 519-637-2646 | Fax consult Speaks Arabic |
| Dr. Kerr, Paul | 1. Pediatrics | Elgin Paediatric Group 426 Talbot St, Suite 103 St Thomas, ON N5P 1B9 | Generic Form | Phone: 519-637-8074 Fax: 519-637-2646 | Fax consult |
| Dr. Blaine, Kirsten | 1. Pediatrics | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult |
| Dr. Gobburu, Ram | 1. Pediatrics | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult |
| Dr. Mitchell, Nadine | 1. Pediatrics | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult |
| Dr. Montiveros, Carolina | 1. Pediatrics | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult |
| Dr. Pittman, Tina | 1. Pediatrics | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult |
| Dr. Purushotham, Hemavathy | 1. Pediatrics | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult Speaks Tamil |
| Dr. Squires, Philip John | 1. Pediatrics 2. Behaviour Disorders (ADHD) | Jenny Trout Centre 342 Erie St, Suite 113 Stratford, ON N5A 2N4 | Generic Form | Phone: 519-272-2040 Fax: 519-272-2323 | Fax consult Speaks French |
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