To book your first visit to the Vancouver fertility clinic:

If your physician hasn’t already sent a referral, please download the appropriate form below and have them fax it to our office.

If you do not have a referring physician, or its difficult for you to obtain a referral from your doctor, we recommend obtaining a referral via EQ Virtual.

To self-refer: Please note there is a $100 private non-refundable fee for self-referrals, due at the time of booking. Fill in the self-referral form below or contact our Referral Coordinator at:

604-422-7276 or toll free at 1-866-481-7276

Email: referrals@pacificfertility.ca

Referral Forms

PCRM Fertility Referral Form Fax to: 604-434-5522
PCRM Prenatal Screening & NIPT Referral Form Fax to: 604-434-5522
PCRM Appointment Cancellation Policy

Self Referral Form

First Name*
Last Name*
Sex*
- Male
- Female
Birth Date*
Date Format: MM slash DD slash YYYY
Phone Number*
Family Physician*
Provincial Health Plan Number*
Email*
Street Address*
City*
Province*
Postal Code*
Have you had previous fertility testing? If yes, what tests were done and what was found?
Have you had previous fertility treatment? If yes, where ?
Do you have a partner?
- Yes
- No
Partner's Name
Partner's Birth Date
Date Format: MM slash DD slash YYYY
Partner's Provincial Health Plan Number
*
- I acknowledge a Self-Referral is not covered by BC MSP and a non-refundable $100 fee will be due upon booking an appointment.

Request an Appointment

To book your first visit to the Vancouver fertility clinic:

Referral Forms

Self Referral Form

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