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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

Chronic Disease and Medicine
Chronic Pain Clinic Referral Form (SL1279)
Complex Continuing Care Referral Form (SL1040)
Diabetes Education Clinic Referral (SL2254)
Geriatric Outpatient Services Referral Form (SL0338)

Diagnostic Assessment Unit
Fit Positive Colonoscopy Referral Form
Physicians use this form to refer patients to the Diagnostic Assessment Unit for colonoscopy in cases where there has been a positive FIT.

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 (SL 1568)
Form for physician to refer patients to the Prostate Assessment Clinic in the Diagnostic Assessment Unit

For for physicians to refer patients for a Skin Cancer Diagnostic Assessment

Diagnostic Imaging

Laboratory Medicine

Pulmonary Function

The forms below are to be completed by doctors referring patients to Southlake for rehabilitation services.  

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