Referral Request

Thank you for your referral. All appropriate patients (including inpatients at other facilities) will be scheduled for an initial consultation at Toronto Western Hospital within 72 hours following your request.

DISCLAIMER: Please note that if you are referring an inpatient from your current facility, all transportation should be arranged by your facility.

Please only send anonymized data with this request form, this server does not protect patient identity.

Patient Information

Physician Information

Urgent referral

Please contact 416-603-2581 and ask to be directed to the neuro-interventional on-call.

Reason for referral:

Brain aneurysmBrain arteriovenous malformation (AVM) / dural fistulaCarotid stenosisQuery venous stenosis / potential stenting (Idiopathic intracranial hypertension (IIH) and/or pulsatile tinnitus)Spinal arteriovenous malformation / fistula Cavernous malformationOther

(Please note that you will receive an answer to your request for urgent consultations, e.g. symptomatic carotid disease or large aneurysms, in 3 to 5 business days. These patients will be prioritized and seen very soon. Non-urgent referrals will be triaged accordingly.)

Supporting documents and information

Please fax supporting documents to 416-603-2581 or email to info@neurologytwh.com with the subject “Referral” *

I confirm that I will fax or email supporting documents