Referral Forms 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.

• Audiology Physician Referral Form

• Breast Assessment Program Imaging Requisition

• Cardiac Rehabilitation Centre Referral

• Chronic Pain Clinic Referral Form (Anesthesiology)

• Colorectal Cancer Screening Referral Form

• CT Requisition: Used at both HDH and KGH.

• Diabetes Education & Management Centre Referral Form

• Registered Nurse Performed Flexible Sigmoidoscopy Referral Form

• GI Function Testing Unit Breath Test & Fecal Fat Requisition
  Fecal Fat Test Instructions

• Heart Failure Clinic, Brock 1

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

• Consultation for Interventional Radiology: Used only at KGH.

• Pastoral Care Referral
  Community based healthcare professionals referral form click here

Patients: You must be referred by a physician/healthcare professional, please do not submit forms on your own behalf.