Refer to Pollin Toronto

Please select one of the four 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 and complete our form and fax to (437) 702-0876


3. Refer to Pollin via the OceanMD Health Map: https://oceanhealthmap.ca/

Patient referral form

*all fields must be completed prior to submission

Physician Information

Referring physician (Name)*

Date *

Billing # *

Phone Number *

Fax

Email

Referral to:

Dr. Kim Garbedian, MD, FRCSC

Dr. Evan Taerk, MD, FRCSC

Dr. Vasilia Vastis, MD, FRCSC

Dr. Cassandra Greenberg, MD, FRCSC

First available appointment

PATIENT DEMOGRAPHICS (as per health card):

Name *

DOB *

OHIP# *

Phone *

Sex at Biirth *

Male

Female

Select the specific service you are referring your patient to:

Fertility

Pregnancy Loss

Egg, Sperm or Embryo Freezing

LGBTQ+ / Third Party

Second Opinion Case Review

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.