Referral Forms for Healthcare Professionals

Forms for physician/healthcare professional use only.

The forms attached below are posted as Adobe PDF files and you require Adobe Acrobat in order to view these forms. In some cases you may be able to fill the form in online and then print, however, you may have to print the form first then fill it in and fax to the number on the form.

Please ensure that you are faxing all forms to the correct fax number.

Adult Eating Disorders Program

South Eastern Ontario Addictions & Mental Health Service Access Form

Adult-Mental Health Services Referral Form

South Eastern Ontario Addictions & Mental Health Service Access Form

Audiology Physician Referral Form

Breast Assessment Program Imaging Requisition

Cardiac Diagnostic Test Requisition

Cardiac Rehabilitation Centre Referral

For more information visit Cardiac Rehabilitation Centre

Child & Adolescent Eating Disorder Program Referral

Chronic Obstructive Pulmonary Disease (COPD) Referral Form

Chronic Pain Clinic Referral Form (Anesthesiology)

Legend:

  • CT -  Computerized Tomography
  • EMG - Electromyography
  • MRI - Magnetic Resonance Imaging
  • DND - Department of National Defence (Canada)
  • ODSB - Ontario Disability Support Program
  • WSIB - Workplace Safety and Insurance Board

Colorectal Cancer Screening Referral Form

Consultation for Interventional Radiology

Used only at KGH.

CT Requisition

Used at both HDH and KGH.

Diabetes Education & Management Centre Referral Form

Fecal Fat Test Instructions

Flexible Sigmoidoscopy Referral Form (Registered Nurse Performed)

GI Function Testing Unit Breath Test & Fecal Fat Requisition

Heads Up! Early Psychosis Intervention Program

Heart Failure Clinic, Brock 1 Referral Form

Hip and Knee Referral Form

Imaging Services Requisition

Used at both HDH and KGH; applies to General Radiology, Ultrasound & Nuclear Medicine studies (NOT to be used for breast imaging).

Mohs Clinic Referral Form

Ophthalmology Referral Form

Emergency eye clinic and General Ophthalmology. Urgent consults (<24h) must be discussed directly with on-call resident available through HDH or KGH switchboard.

Pulmonary Function Laboratory Referral & Test Request

Telemedicine Clinical Referral