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 |
|---|---|---|---|---|---|
| Hand and Upper Limb Clinic | 1. Medical and Surgical Care for hands and upper limbs | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6000 ext 64944 Fax: 519-646-6049 | Fax Referral Website |
| LHSC ER Plastic Surgery Clinic Referral (VH Only) | 1. Plastic Surgery (Adult & Peds) (VH Only) | LHSC – Victoria Hospital | VH Outpatient Referral | Phone: 519-685-8500 x 58178 Fax: MD on call | Fax consult Clerk to book appointment |
London Physicians
| London Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Gan, Bing Siang | 1. Plastic Surgery 2. Hand & Wrist Surgery 3.Reconstructive Microsurgery 4. Complex Wound Reconstruction | St. Joseph’s Healthcare Centre | HULC Referral Form | Phone: 519-646-6097 Fax: 519-646-6049 | Fax consult |
| Dr. Gillis, Josh | 1. Plastic Surgery 2. Hand & Wrist Surgery 3. Brachial Plexus / Nerve Surgery 4. Reconstructive Microsurgery | St. Joseph’s Healthcare Centre | Generic Form | Phone: 519-646-6326 Fax: 519-646-6378 | Fax consult |
| Dr. Richards, Robert | 1. Plastic Surgery 2. Hand & Wrist Surgery 3. Cosmetic Surgery | Generic Form | Phone: 226-637-6046 | Fax consult | |
| Dr. Ross, Douglas | 1. Plastic Surgery 2. Hand & Wrist Surgery 3. Peripheral Nerve Surgery 4. Cosmetic Surgery | St. Joseph’s Healthcare Centre | HULC Referral Form | Phone: 519-646-6049 Fax: 519-646-6049 | Fax consult |
| Dr. Evans, Brian | 1. Plastic Surgery 2. Craniofacial Surgery 3. Cosmetic Surgery | Thompson Medical Centre 990 Gainsborough Road London, ON N6H 5L4 | Generic Form | Phone: 519-601-8621 Fax: 519-204-3122 | Fax consult |
| Dr. Grant, Aaron | 1. Plastic Surgery 2.Melanoma Excision 3. Breast Reconstruction | LHSC – University Hospital | Generic Form | Phone: 519-663-3321 Fax: 519-663-3289 | Fax consult |
| Dr. DeLyzer, Tanya | 1. Plastic Surgery 2. Complex Wound Reconstruction 3.Post-Oncologic Resection 4. Burn Care | LHSC – Victoria Hospital | Generic Form | Phone: 519-685-8108 Fax: 519-685-8114 | Fax consult |
| Dr. Symonette, Caitlin | 1. Plastic Surgery 2. Pediatric Plastic Surgery 3. Hand & Reconstructive Surgery | LHSC – Victoria Hospital | Generic Form | Phone:519-667-6757 Fax: 519-667-6761 | Fax consult |
| Dr. Yazdani, Arjang | 1. Pediatric Plastic Surgery 2. Craniofacial Surgery (Adult + Peds) 3. Ear Reconstruction 4. Vascular Abnormalities 5. Cosmetic Surgery | Children’s Hospital London Health Sciences Centre | Generic Form | Phone: 519-601-4554 Fax: 519-601-4559 | Fax consult Website |
| Dr. Marignani, Marilena | 1. Plastic Surgery 2. Skin cancer 3. Cosmetic Surgery | 272 Oxford St W London, ON N6H 1S9 Privileges – Strathroy | Generic Form | Phone: 519-438-1130 Fax: 519-438-0861 | Fax consult |
| Dr. Colcleugh, Robert | 1. Plastic Surgery 2. Skin Cancer | Medpoint Health Care Centre – Citi Plaza 355 Wellington St, Suite 233 London, ON N6A 3N7 | Medpoint Referral | Phone: 519-432-1919 Fax: 519-432-9529 | Fax consult |
| Dr. Overduin, Tola (Afolabi) | 1. Plastic Surgery 2. Skin Cancer | Medpoint Health Care Centre – Citi Plaza 355 Wellington St, Suite 233 London, ON N6A 3N7 | Medpoint Referral | Phone: 519-432-1919 Fax: 519-432-9529 | Fax consult |
| Dr. Hasegawa, Brian | 1. Plastic Surgery (cosmetics) | Medpoint Health Care Centre – Riverbend 200-1295 Riverbend Rd London, ON N6K 0G2 | Medpoint Services Referral | Phone: 519-432-1919 Fax: 519-432-9529 | Fax consult |
Stratford Physicians
| Stratford Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Heaton, Graham | 1. Plastic Surgery 2.Cosmetic Surgery | 378 Huron St Stratford, ON N5A 5T5 | Generic Form | Phone: 519-305-3550 Fax: 519-305-3552 | Fax consult Website |
Pediatric Physicians
| Pediatric Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Matic, Damir | 1. Pediatric Plastic Surgery 2. Craniofacial Surgery 3. Cleft Surgery | Children’s Hospital London Health Sciences Centre | Generic Form | Phone: 519-685-8557 Fax: 519-685-8405 | Fax consult Website |
| Dr. Symonette, Caitlin | 1. Plastic Surgery 2. Pediatric Plastic Surgery 3. Hand & Reconstructive Surgery | LHSC – Victoria Hospital | Generic Form | Phone:519-667-6757 Fax: 519-667-6761 | Fax consult |
| Dr. Yazdani, Arjang | 1. Pediatric Plastic Surgery 2. Craniofacial Surgery (Adult + Peds) 3. Ear Reconstruction 4. Vascular Abnormalities 5. Cosmetic Surgery | Children’s Hospital London Health Sciences Centre | Generic Form | Phone: 519-601-4554 Fax: 519-601-4559 | Fax consult Website |
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