We are accepting patients with referrals! Walk-in hours are for urgent care only

Home
Our Services
Contact Us
Our Team
Parent Resources
Photo Gallery
Policies
Clinic Blogs
More

Home
Our Services
Contact Us
Our Team
Parent Resources
Photo Gallery
Policies
Clinic Blogs

Physicians Referral Form

Please fill out the following form

Referring Physician Signature*

Physician's Billing Number*

Physician's Phone Number*

Physician's Fax Number*

Patient's First Name*

Patient's Last Name*

Patient DOB (MM/DD/YYYY)*

Patient's Phone Number*

Email*

OHIP

Attachment if any

Attachments (0)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Copyright © 2025 Millcreek Children's Clinic - All Rights Reserved.

This website uses cookies.

We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.