Dr. Serge Goekjian Referral Form

ONTARIO ASSOCIATION OF CRANIOFACIAL TRAUMA SURGEONS (OACTS) REFERRAL FORM
DR. SERGE GOEKJIAN
MD, MSc, FRCS(C)
PLASTIC AND RECONSTRUCTIVE SURGEON
OAKVILLE TRAFALGAR MEMORIAL HOSPITAL
2525 OLD BRONTE ROAD, SUITE 560
OAKVILLE, ONTARIO, L6M4J2
PHONE: 289 386 3636
FAX: 289 386 3536
PATIENT ID STICKER
Max. file size: 64 MB.
Patient’s Contact Phone Number
Direct referrals to Dr. Goekjian 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