Request a consultation

CONTACT INFORMATION

I am completing this form for :

Myself

Someone else

Last name *

First name *

Email *

Please enter a valid email address.

Phone number 1 *

This field is required.

Please enter a valid phone number (123-456-7890). *

Type *

This field is required.

SECTION 1 - PATIENT INFORMATION

Last name *

This field is required.

First name *

This field is required.

Date of birth (YYYY-MM-DD) *

This field is required.

I do not have a health insurance number

Health insurance card number *

This field is required.

Expiration date-year *

This field is required.

Expiration date-month *

This field is required.

MUHC Hospital Card number

Email *

Please enter a valid email address.

Do you have a permanent address ?

Yes

No

ADDRESS *

Apartment number, Street number, Street name *

This field is required.

City *

This field is required.

Province *

This field is required.

Postal code (H1H 1H1) *

This field is required.

Please use the format H1H 1H1.

Phone number 1 *

This field is required.

Please enter a valid phone number (123-456-7890). *

Type *

This field is required.

Phone number 2

Please enter a valid phone number (123-456-7890).

Type

This field is required.

The MUHC offers consultation confirmation via text message (SMS). If a cell phone number is provided on this form, it will be used to confirm your consultation.

REFERRING PHYSICIAN

Last name *

This field is required.

First name

Name of the clinic

Phone *

This field is required.

Please enter a valid phone number (123-456-7890).

Extension number

Fax number

REQUEST FOR MEDICAL CONSULTATION

Reason for referral to MUHC specialist : Please type what is written on the physician’s request (if the reason of the consultation is unclear, please indicate UNCLEAR). *

This field is required.

Specialty requested (Please choose from the dropdown menu) If you are not sure, please indicate "I don't know."

Note: We make every effort to respect your choice of site. Some specialties have clinics at all MUHC sites. In these cases, patients will be scheduled at the site with the soonest opening. You will be told where to go when you are given an appointment.

Does the referral say you should see a specific doctor at the MUHC?

Yes

No

Upload a file

This field is required.

Accepted file types: jpg, png, pdf, jpeg. Max. file size: 2 MB. Please make sure that your attachment is clear and legible. We do not process incomplete applications or provide appointments without a copy of the referral. If you do not attach your referral, you will need to fax it to the department directly. Wait times depend on the priority assigned to the referral and can be as long as several months.

Please ensure that the uploaded document corresponds to the consultation request. Any discrepancy may result in the refusal of your consultation request.

Please upload your referral. *

Upload a file

This field is required.

Accepted file types: jpg, png, pdf, jpeg. Max. file size: 2 MB. Please make sure that your attachment is clear and legible. We do not process incomplete applications or provide appointments without a copy of the referral. If you do not attach your referral, you will need to fax it to the department directly. Wait times depend on the priority assigned to the referral and can be as long as several months.

Please ensure that the uploaded document corresponds to the consultation request. Any discrepancy may result in the refusal of your consultation request.

TESTS PERFORMED IN THE LAST THREE (3) MONTHS

Please check off all relevant tests performed in the past three (3) months. If “Other testing” is checked off, please specify.

Imaging and Radiology

Laboratory testing

Biopsy

Other testing:

Do you have any extra information we should know?

Please review before submitting your request.

I confirm that the information I entered on this form is accurate.

You must confirm the information before submitting.

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Referral Portal