Physician Referral

Date* :

Referring Doctor’s Information :

Name* :

Billing Code* :

Street Address* :

City* :

Province/Territory/State* :

Country* :

Postal Code/Zip Code* :

Phone Number* :

Email:

Fax* :

Referred Patient’s Information:

First Name* :

Last Name* :

Date of Birth* :

Email :

Phone Number* :

Reason for Referral :

**Please note there is $100 fee if patient does not show up for scheduled appointment

This referral will be addressed to Markham Fertility Centre and the patient will be assigned to one of our expert specialists. When a physician completes this online referral with patient information, they are giving MFC permission to contact the new referral at any of the information provided including but not limited to phone, email or mail.