Stronach Regional Cancer Centre

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

Diagnostic Imaging

CT Scan (SL 0260)

CT Scan (fillable) (SL 0260)

MRI Patient Screening Form (SL 0273)

MRI (SL 0274)

MRI (fillable) (SL 0274)

Radiology (SL 0453)

Ultrasound and Vascular (SL 0454)

Nuclear Medicine (SL 0455)

Interventional Radiology – Special Procedure (SL 0640)

Coronary CT Angiography (SL 0915)

Coronary CT Angiography (fillable) (SL 0915)

Nuclear Medicine Cardiac Requisition (SL 0067)

Mammography, Bone Density, X-Ray, Breast Ultrasound Requisition (SL 0002)




 

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.