Appointment with a specialist

To request an appointment with a specialist, please fill out the form below. Incomplete applications will not be processed. Wait times depend on the priority assigned to the referral and may take up to several months.

Exceptions:

For the Neurology Clinic, please send your request to : [email protected]
For the Mild Traumatic Brain Injury Clinic (MTBI), ask the specialist for a referral to the concussion clinic.
For the Rheumatology Clinic, please fax your request to 514-412-4365.

If you are looking for a pediatrician, please visit this link.

For any questions, please call the Appointment Referral Centre at 514-412-4040 or contact us at [email protected], with the following information:

Name of child
Two telephone numbers where you can be reached during office hours (8:00 a.m. to 4:00 p.m.)

Clinic / specialty you are requesting an appointment for
Your doctor’s referral uploaded as an attachment, if this is a first appointment in the clinic

In case of an emergency, contact your family physician, call 811, or go to the nearest Emergency.

1. If this is your first visit to the clinic you are being referred to, fill out this section. If it is for a follow-up, start at section 2.

Name of doctor who referred you

Referring physician's licence number (if available)

Diagnosis or reason for this appointment (as indicated on the referral)

Attach a referral

Please make sure your attachment is clear and legible. Documents that are blurry, dark or extremely large or small will not be accepted. Please note that if you do not attach your referral, you will be asked to fax it to the department directly. No appointments are provided without a copy of the referral. To obtain the fax number of the department you are being referred to, please consult our directory: http://www.thechildren.com/departments-staff/departments.
Files must be less than 2 MB.
Allowed file types: jpg jpeg png pdf doc docx.

Photos of documents are not accepted

Medical specialty or clinic name for your appointment

Name of doctor you were referred to (if applicable)

Is this your first visit to The MCH ?

yes

2. Return visit

What specialty/service/department did you see this physician in?

When did your physician request to see your child again?

3. Patient Information

Child's last name *

Child's first name *

Date of birth *

Month

Day

Year

Age *

Health care card (medicare card) number *

Health care card expiration date *

Month

Day

Year

MCH Medical Record number (if known)

(upper right corner of MCH red hospital card)

Address (street) *

City *

Province *

Postal Code *

4. Contact Information (for parent or guardian)

Your last name *

Your first name *

Your relationship to patient *

Daytime phone number *

Alternate phone number *

Email address

Appointment with a specialist

GETTING TO THE HOSPITAL