Refer to Pollin

Please select one of the three referral options provided below. Once completed, Pollin will promptly contact the patient regarding appointment specifics. We look forward to providing the best care for your patient.‍

1. Refer to Pollin via Online Form: Complete the referral using the form below.

2. Refer to Pollin via Fax: Download our form and fax to (437) 702-0876


Patient referral form

*all fields must be completed prior to submission

Physician Information

Referring physician (Name)*

Date *

Billing # *

Phone Number *

Fax

Email

Referral to:

Kim Garbedian, MD, FRCSC

Evan Taerk, MD, MSc, FRCSC

Dr. Shirin Dason, MD, FRCSC

First available appointment

PATIENT DEMOGRAPHICS (as per health card):

Name *

DOB *

OHIP# *

Phone *

Select the specific service you are referring your patient to:

My Fertility IQ

Fertility

Pregnancy Loss

Egg, Sperm or Embryo Freezing

LGBTQ+ / Third Party

Other

Additional Comments

Thank you for entrusting your patient’s fertility care with Pollin.

Pollin will contact your patient with the appointment date & time, including any instructions for the appointment.

Thank you! Your referral has been received!

Oops! Something went wrong while submitting the form.