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Requisition and Referral Forms
Below is an index of referral and requisition forms to refer patients to Southlake services. These forms must be completed by a healthcare professional, i.e. doctor. 

If you feel that you should be referred for one of these services please speak with your doctor.  

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








Diagnostic Assessment Unit
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.
Diagnostic Assessment Unit Breast Clinic Physician Referral (SL0806)
Physicians must use this form to refer patients to the Diagnostic Assessment Unit Breast Clinic. 
Lung Diagnostic Assessment Program Referral Form (SL1697)
Physicians use this form refer patients to the Lung Diagnostic Assessment Program.
Prostate Assessment Clinic Physician Referral Form (SL1568)
Form for physician to refer patients to the Prostate Assessment Clinic in the Diagnostic Assessment Unit


 

Mental Health 
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

Rehabilitation



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
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