Physician & Nurse Practitioner Referrals MD/NP Referrals Send a referral for either the Cardiometabolic Health – Lifestyle Medicine Program or General Internal Medicine clinic. MD/NP Confirmation(Required) I confirm that I am a physician or nurse practitioner (or their delegate) licensed to practice in Ontario.We are only able to accept referrals from providers with a valid OHIP billing number.Type of referral(Required) Cardiometabolic Health – Lifestyle Medicine Program General Internal Medicine Consultation Patient is aware of this referral?(Required) Yes No Patient is aware of this referral and that private pay services are part of the Program?(Required) Yes No Patient Name(Required) First Last Date-of-Birth(Required) YYYY slash MM slash DD Phone(Required)Patient Email Health Card Number(Required)Version Code(Required)Patient Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Preferred Consult Method(Required) In-person Virtual *Our clinic is located at University Hospital in London, Ontario.Referring MD/NP(Required) First Last Billing Number(Required)Reason for Referral(Required)cardiometabolic health assessmentpre diabetesdiabetesobesityhypercholesterolemiahypertensioncoronary artery diseasechronic kidney diseasesleep apneacerebrovascular diseaseother (specify below)Other – specifyBrief Description/Clinical QuestionAttach supporting documents for referral Drop files here or Select files Max. file size: 64 MB. Patient CPP, recent lab work or investigationsCAPTCHA Δ
