Dr. Jeffrey Fialkov Referral Form

ONTARIO ASSOCIATION OF CRANIOFACIAL TRAUMA SURGEONS (OACTS) REFERRAL FORM
DR. JEFFREY FIALKOV
MD, MSc, FRCS(C)
PLASTIC AND RECONSTRUCTIVE SURGEON
SUNNYBROOK HEALTH SCIENCES CENTRE
2075 BAYVIEW AVENUE, SUITE M1-524
TORONTO, ONTARIO, M4N 3M5
PHONE: 416 480 4257
FAX: 416 480 4224
PATIENT ID STICKER
Max. file size: 64 MB.
Patient’s Contact Phone Number
Direct referrals to Dr. Fialkov should be made for non-urgent facial fractures (see list below). For any other facial fractures requiring urgent assessment or management (i.e. intra-cranial injury, airway compromise, retrobulbar hematoma, orbital muscle entrapment) please call CritiCall at 1-800-668-4357.
DATE OF REFERAL
MM slash DD slash YYYY
DATE OF INJURY
MM slash DD slash YYYY
REASON FOR REFERRAL
DIAGNOSIS
- Nasal bone fracture
- Zygoma fracture
- Orbital Fracture
- Maxilla fracture
- Mandible Fracture
- Frontal Sinus Fracture
- Other
If other, please describe.
DIAGNOSTIC IMAGING PERFORMED
- Plain Films
- CT Scan (Facial Views)
LOCATION OF IMAGING
C-SPINES CLEARED
- Yes
- No
OPHTHAMOLOGY CONSULT
- Yes
- No
REFERRING PHYSICIAN INFORMATION
Name
First Last
Billing Number
Phone
Fax
Email
Signature of Referring Physician
Please Fax all referral forms to Fax number listed above and send all relevant diagnostic imaging with the patient (CT facial bones). All trauma patients should have their C-spines cleared and a referral to Ophthalmology for all orbital trauma.

ONTARIO ASSOCIATION OF CRANIOFACIAL TRAUMA SURGEONS (OACTS) REFERRAL FORM