Dr. Tara Lynn Teshima Referral Form

ONTARIO ASSOCIATION OF CRANIOFACIAL TRAUMA SURGEONS (OACTS) REFERRAL FORM
DR. TARA LYNN TESHIMA
MD, MSc, FRCS(C)
PLASTIC AND RECONSTRUCTIVE SURGEON
MARKHAM STOUFFVILLE HOSPITAL
377 CHURCH STREET, SUITE 208
PHONE: 289 597 6775
FAX: 289 459 0221
PATIENT ID STICKER
Max. file size: 64 MB.
Patient’s Contact Phone Number
Direct referrals to Dr. Teshima 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