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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
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

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


Diagnostic Imaging
Radiography Requisition (SL1768) 
(General Radiography, Gastrics, Special Procedures (e.g. IVP, arthrogram))


Laboratory Medicine


Neurology
Pulmonary Function

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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