Professionnels de la santé

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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

Breath Tests - Fecal Fat Registion

Cardiac Diagnostic Test Requisition

Cardiac Rehabilitation Centre Referral

Child & Youth Mental Health Referral Forms

Referrals from Physicians, Family Health Teams and Nurse Practitioners in Kingston, Frontenac, Lennox and Addington (KFL&A) are processed through our Centralized Triage process in collaboration with our partners at The Maltby Centre (formally known as Pathways for Children and Youth) who are the lead children’s mental health agency in KFL&A.  Referrals can also be sent directly to our program from community professionals such as School Boards and Children’s Mental Health Agencies. Physicians, Family Health Teams, and Nurse Practitioners from outside of KFL&A can also refer to our services, and referrals will be triaged accordingly.

Chronic Obstructive Pulmonary Disease (COPD) Referral Form

Chronic Pain Clinic Referral Form (Anesthesiology)


  • 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

May 2019

Colorectal Cancer Screening Referral Form

Please Note: our Referral Form has changed to a fillable PDF and now includes the choice of FIT screening.

Colorectal Diagnostic Assessment Program - Referral Form

South East Regional Cancer Program in parnership with Cancer Care Ontario

Consultation for Interventional Radiology

Used only at KGH.

CT Requisition

Used at both HDH and KGH.

Dermatology Clinic

Referral Guidelines for General Dermatology.

Diabetes Education & Management Centre Referral Form

GI Function Testing Unit Breath Test & Fecal Fat Requisition

Heads Up! Early Psychosis Intervention Program

Heart Failure Clinic, Brock 1 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).

Lung Diagnostic Assessment Program (Lung DAP) - Referral Form

South East Regional Cancer Program in partnership with Cancer Care Ontario

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

SE LHIN Hip and Knee Arthritis Referral Form

Telemedicine Clinical Referral

Vestibular Function Lab Referral Form

Standard VNG/ENG*
Fistula test (Impedance Bridge)
Air Calorics
*Includes: Gaze tests, Saccades, Tracking, Optokinetic tests, Positions, Headshaking,
Spontaneous, and Water Caloric Tests

Vision Rehabilitation Referral Form

The South East Ontario Vision Rehabilitation Service (SOVRS) is a collaboration between Kingston Health Sciences Centre’s Vision Rehabilitation Clinic and Vision Loss Rehabilitation Ontario (a division of the Canadian National Institute for the Blind). We provide assessment and interventions services to support individuals with vision loss (e.g., low vision assessment, training on adaptive strategies, equipment trials, system navigation, etc.).

For diagnosis and medical management of visual issues or for standard prescription eyewear, please first refer patients to the ophthalmology department or a community optometrist, as appropriate. Should it be determined your patients have residual vision loss that cannot be corrected, they are then appropriate for a SOVRS referral. For any questions regarding referral, please call 613-542-4975, ext. 5081.