Secure referral form

For physicians and health providers

To submit a referral online, please complete the following form. To submit a referral via fax, please send to 647-558-0546.

We will contact the patient directly to schedule an appointment. If we are unable to see your patient, we will contact your office to let you know.

Referral

Referring physician

Name

Phone

(###)

###

####

Office Address

Referred Patient

Name

Date of Birth

YYYY

Phone 1

(###)

###

####

Reason for Consultation Request:

This patient has consented to this referral and has been informed that he/she will be contacted by Well Said: Toronto Speech Therapy to schedule a non-OHIP covered appointment.

Yes

Secure referral form

For physicians and health providers

Referral

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