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

3. Refer to Pollin via Email: Download our form and send to

Download the pdf form

Patient referral form

*all fields must be completed prior to submission

Physician Information

Referral to:

PATIENT DEMOGRAPHICS (as per health card):

Select the specific service you are referring your patient to:

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!
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