Online Referral

An OHIP covered service
Patients must be 16 years or older
FHO and FHG billings will not be affected
We do not see patients outside of the referral criteria
The clinic is run entirely by Internal Medicine Physicians
Our clinic focuses on the medical management of patients with obesity and related comorbidities

Patient Information

Patient's Name:

Patient's Phone:

Patient's E-mail:

Patient's Healthcard Number:

Referring Physician:

Office Address:

Office Phone:

Office FAX:

OHIP Billing Number:

Obesity Classification

Class Overweight With Obesity

Overweight

BMI>27 (Non-Asian) BMI>25 (Middle East) BMI>23 (South Asian/South East Asian/Asian Pacific)

With Obesity

BMI>30 (Non-Asian) BMI>27 (Middle East) BMI>25 (South Asian/South East Asian/Asian Pacific)

AND (select at least one):

Past Medical History:

Updated Medication List:

Other Information: