Self Referral

To submit the form online please fill out the form below and click submit when your finished. If you do not wish to submit online, please scroll down to the Offline Self Referral section.

Self Referral Form
Lakeridge Fertility Clinic
Telephone: 905-493-9222
Fax: 905-493-9221
Website: www.lakeridgefertility.com
Address: 619 Brock St. South Whitby, Ontario
Postal Code: L1N 4L1

When to Refer

  • Female partners under 35 and trying to conceive for 12 months or more
  • Female partners 35 or older and trying to conceive for 6 months or more
  • Irregular menses, know male factor, know tubal factor or endometriosis, prior fertility treatment
  • Fertility concerns

Reason for Referral

Please forward any relevant investigations regarding sperm analysis, laboratory investigations or tubal status.

Patient Details

  • Name (as per your Health Card):
  • Date of Birth:
  • OHIP#:
  • Full Mailing Address:
  • Contact Number

Partner Details

  • Name (as per your Health Card):
  • Date of Birth:
  • OHIP#:
  • Full Mailing Address:
  • Contact Number

Urgent Requests: Call 905-493-9222 and ask to speak with Nurse Coordinator

Please note: if you are self referring your significant other must attend the consultation.
Patients will be contacted with appointment date and time.

captcha

Offline Self Referral

Click this link: Self Referral PDF to open a pdf version that you can fill out and print. To fill out the pdf just click on the field (anything underlined) and type your answer. When you are ready to print out the document just look for your browser’s print button.(The PC’s short cut for print is press both “crtl” and “P” keys at the same time.) If you wish you may also fill the form out by hand, just open the pdf link and print it out. If you choose to not fill out the form online; please submit the completed form either through fax at 905-493-9221 or send in the form to the clinic. The clinic is located at 619 Brock St. South, Whitby, Ontario L1N 4L1.