Referrals. Families can book an appointment without a referral.A health care provider referral for circumcision is always welcome! Referrals can be completed using the online referral form.Referrals can be made manually by completing this form: PDF Referral Form.Please fax this form to (647) 476-7007. Online referral form Reason for referral * Primary circumcision for babies 0 - 6 months old Revision circumcision for redundancy 0 - 6 months old Skin bridge and adhesion separation 0 - 12 months old Referring provider’s Name * Referring provider’s Email * Referring provider’s Billing Number Referring provider’s Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referring provider’s Phone * (###) ### #### Referring provider’s Fax * (###) ### #### Parent or Guardian Name(s) * Parent or Guardian Phone * (###) ### #### Parent or Guardian Email * Baby / Child's Name * First Name Last Name Baby / Child Date of Birth * MM DD YYYY Child / baby's Health Card Number Child / baby's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!Someone from our team will confirm the appointment with both the referring provider and the family within one business day.