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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

Cancer Centre Referral Form (out-patient)
For more information about referring to the Stronach Regional Cancer Centre at Southlake, click here.
Flexiable Sigmoidoscopy Referral Form (SL1760)
Outpatient Psychosocial Oncology & Palliative Care Referral Form
Patient Cancer Referral Form (SL0580)

Cardiac
Cardiac Diagnostic Requisition (SL0071)
Cardiovascular Prevention and Rehabilitation Program Referral Form (SL0477)
Cardiology Clinic Referral Form
Heart Function Program Referral Form (SL0262)
Pacemaker Referral Form (SL1032)
Tilt Table Test Referral (SL1060)
TAVI Referral Form (SL1144)


Chronic Disease and Medicine
Adult Asthma Program Referral Form (SL1260)
Chronic Pain Clinic Referral Form (SL1279)
Complex Continuing Care Referral Form (SL1040)
Diabetes Education Clinic Referral (SL0820)
Geriatric Outpatient Services Referral Form (SL0338)


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


 
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
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