Refer a Carotid Case to Acute Carotid Clinic (ACC)

Thank you for your referral. All appropriate patients (including inpatients at other facilities) will be scheduled for an initial consultation at St. Michael’s Hospital within 6 to 72 hours following your request.

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

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

Please fax the referral to Fax#: 416-864-5176 as soon as you complete this form. Please also include the following in your fax: patient demographics, tests reports, recent blood work, medication list, and any other relevant medical notes.

Physician First Name

Physician Last Name

OHIP Billing Number

Cell or Pager Number

We can call you here.

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Case Description

Write a brief ANONYMIZED patient description. Include details such as: sex, age, symptoms, onset, known history of progression. (e.g. 72 y/o male with right face, arm and leg weakness for 20 minutes on March 19th Carotid Doppler from March 20th shows left ICA Stenosis of 70-99%)

Refer a Carotid Case to Acute Carotid Clinic (ACC)

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