Referrals & Requisitions

Please Note: The following documents are for use by healthcare professionals only. If you have a new version of a form to post please e-mail it to mlougheed@gbhs.on.ca.

Cardiac Rehabilitation

• Cardiac Rehabilitation Referral

Cardiology

• Echocardiography Requisition

Diabetes

• Grey Bruce Diabetes Program Referral Form
• Diabetic Foot Ulcer Referral Form

Diagnostic Assessment Clinic

• Thoracic Assessment Clinic Referral Form
• Prostate Assessment Clinic Referral Form

Geriatric

• Geriatric Medicine Referral Form

Lab Requisitions

• Therapeutic Phlebotomy Requisition

Medical Assistance in Dying (MAID)

• MAID referral form to SW LHIN
• Clinician Aid A Form – for patient
• Instructions for Completing Clinician Aid A form

Medical Imaging

• CT Requisition
• CT Spine Appropriateness Checklist
• General Medical Imaging Requisition
• Interventional Radiology Request
• MRI Breast Questionnaire
• GBHS MRI Requisition
• Regional MRI requisition
• Mammography and Breast Screening Requisition
• MRI Knee Appropriateness Checklist
• MRI Spine Appropriateness Checklist
• Patient Preparation for Imaging Tests
• Request for Bone Mineral Densitometry

Mental Health and Addictions

• Adult Psychiatric Referral
• Child & Youth Psychiatric Referral
• Psychogeriatric Referral Form

Physiotherapy & Occupational Therapy

• Physiotherapy Occupational Therapy Outpatient Referral Form

Rehabilitation

• Rehab Referral Form

Respiratory Therapy / Sleep Clinic

• Respiratory Therapy Outpatient Test Requisition
• Sleep Clinic Referral Form

Stroke Centre

• Stroke Prevention Clinic Referral Form
• Community Stroke Rehab Team

Surgery

• Pre-surgical Screening Questionnaire
• SW LHIN Hip Knee Referral Form