Background: Approximately 95,000 Ontarians, including nearly 15,000 children, have a diagnosis of epilepsy (CCSO, 2015). Management is typically with medication, though surgical resection offers permanent cure in a subsection of patients. A 2012 Health Quality Ontario study estimated a potential 9,300 patients as surgical candidates, but only 150 operations are performed annually, suggesting the surgery option is underutilized. This study attempts to identify reasons for non-referral in a small epilepsy practice. Methods: Evidence based guidelines (Jette, N et al, CMAJ 2014) were used to define eligibility for surgical referral in 274 children with epilepsy. The presence of referral criteria was analyzed. Results: 22 children had clear evidence of drug resistance and one other criteria for referral for epilepsy surgery. 10 referrals had been made. Complex syndromes were present in 40% of the referrals, and 10% of the unreferred. Surgical lesions were present on MRI in 60% of the referrals and 14% of the unreferred. The majority of the unreferred have refractory focal epilepsy but no known surgical abnormality on MRI. Conclusions: In our practice there is a referral bias towards patients with MRI lesions, whereas those without MRI findings tend not to be referred, despite being refractory.