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Requisition and Referral Forms
Stronach Regional Cancer Centre

Cancer Centre Referral Form
For more information about referring to the Stronach Regional Cancer Centre at Southlake, click here.

Outpatient Psychosocial Oncology & Palliative Care Referral Form

Diagnostic Assessment Unit

Prostate Assessment Clinic Physician Referral Form (SL1568)
Form for physician to refer patients to the Prostate Assessment Clinic in the Diagnostic Assessment Unit.

Lung Diagnostic Assessment Program Referral Form (SL1697)
Physicians use this form refer patients to the Lung Diagnostic Assessment Program.

Diagnostic Assessment Unit Breast Clinic Physician Referral (SL0806)
Physicians must use this form to refer patients to the Diagnostic Assessment Unit Breast Clinic.

Colon Cancer Check Referral Form (SL 1367A)
Physicians use this form to refer patients to the Diagnostic Assessment Unit for colonoscopy in cases where there has been a positive FOBT or first-degree relative with history of colon cancer.

Pulmonary Function
Pulmonary Function Requistion Form (SL0738)
Physicians must complete this form to refer a patient for Pulmonary Function Testing, including:
  • Flow-Volume Loop
  • Diffusing Capacity
  • 02 Saturation
  • Lung Volumes by Body Plethysmography

Stroke Prevention
Southlake Regional Health Centre
596 Davis Drive, Newmarket, Ontario   L3Y 2P9
Tel: 905-895-4521   |   TTY: 905-952-3062
Copyright © 2012 Southlake Regional Health Centre