Make a Referral

Upon receipt of referral information, Deena Ginsberg, Practice Director, will follow up with you immediately.

Referrals can be made by phone by calling us at 416.477.3810 ext. 101 or online by filling out the form below.

Client Information

*Client's Last Name:
*First Name:
Middle Name:
*Postal Code:
*Telephone No. (Home):
Telephone No. (Cell):
*Date of Birth:
Gender: MaleFemale
*E-Mail Address:

Referral Source Information

*Referral Name:
*Referral Email:
Name of Agency:
*Telephone No:
Fax No.:
Is this Referral Source information the same as the Legal Representation? Yes

Insurance Information:

Name of Insurer:
Name of Adjuster:
Claim Number
Date of Accident:
Telephone No:
Fax No.: