e-referral

eCHN e-Referral
Application Request Form


 
Please fill out the form below to request an e-Referral account.

If you would like to review referral guidelines
before referring a patient to SickKids: please visit this page.

For urgent referrals only (same day referrals):
contact eCHN's helpdesk directly at 416-813-7998 or 1-877-252-9900 or by email at helpdesk@echn.ca.

On weekends and after 6:00 pm weekdays:
contact the Fellow on call via SickKids locating at 416-813-1500.

First Name *
Last Name *
Profession *

Professional License Number
If any additional staff members will be involved in referral/ monitoring/ follow-up (such as administrative, secretarial staff, etc.), please provide their names:
First Name *
Last Name *
+ Add more (up to 5 total)
Referring Organization Type *

Referring Organization Name *
Mailing Address (Number + street) *
Suite Number
City *
Province *
Postal code *
Telephone (416-813-7998 x123) *

Fax
Email Address *

* Required Field