Referral forms

Please see the referral form or program page for more information.

Acquired Brain Injury: Inpatient Unit

Acquired Brain Injury (ABI) Inpatient Unit referral form
Download the Acquired Brain Injury Inpatient Unit brochure
Patient and family safety on inpatient units brochure

Aging Brain and Memory Clinic

Geriatric Ambulatory Access Team (GAAT) referral form
Parkwood Access Referral Form

Allergy and Immunology Program

Allergy and Immunology referral form

Biigajiiskaan: Indigenous Pathways to Mental Wellness

Biigajiiskaan referral form

Breast Care Program

Breast assessment referral form
Breast surgery referral form

Cardiac Rehabilitation and Secondary Prevention Program

Cardiac rehabilitation referral form

Cardiovascular Investigation Unit

Cardiovascular Investigation Unit referral form

Centre for Diabetes, Endocrinology and Metabolism

Diabetes Education Centre Referral Form
Diabetes Endocrinology ODP Referral Form
Endocrine Pregnancy Clinic Referral Form (Gestational)
Thyroid Cancer Referral Form

Colposcopy

Colposcopy referral form

Community Stroke Rehabilitation Team

Community stroke rehabilitation referral form

Concurrent Disorders Services

Adult mental health ambulatory centralized access point

Dental Centre (inside St. Joseph's Family Medical and Dental Centre)

Dental Centre Referral Form

Diabetes Education Centre

Diabetes Education Centre Referral Form

Driving Assessment Programs at Parkwood lnstitute

Driving Assessment referral form

Electromyography (EMG) Clinic

EMG Referral Form

Heart Failure Clinic

Heart Failure Clinic Referral Form

Ivey Eye Institute

Cataract Central Intake Referral Form
General/cornea/glaucoma diagnostic requisition
Intravenous Fluorescein Angiography Consent
Lenstar testing consent form
Request for Orthoptic Assessment
Retina Diagnostic Requisition

Long-Term Ventilator Care

How to refer a patient to Long-Term Ventilator Care
Long-Term Ventilator Care Referral form

Lung Diseases Program

COPD Program Referral Form
Methacholine challenge referral form
Pulmonary Function Test Requisition
Pulmonary Rehabilitation Referral Form

Medical Imaging

XRAY General Radiology Referral Form

Medical Imaging: Bone Mineral Density (BMD) Testing

Bone Mineral Density (BMD) Referral Form

Medical Imaging: Breast Imaging

Breast assessment referral form

Medical Imaging: CT and CAT

CT Requisition form
CT spine checklist

Medical Imaging: Interventional Radiology

Interventional radiology request form

Medical Imaging: Magnetic Resonance Imaging (MRI)

MRI checklist for spine form
MRI knee appropriateness checklist
MRI referral form (PDF)

Medical Imaging: Molecular Imaging and Theranostics (Nuclear Medicine, PET/CT)

Molecular Imaging and Theranostics (Nuclear Medicine) Referral Form

Medical Imaging: PET/CT (Positron Emission Tomography)

PET/CT referral form

Medical Imaging: Radiology (X-Ray)

XRAY General Radiology Referral Form

Medical Imaging: Ultrasound

Ultrasound requisition

Medically Complex Patients

Complex continuing care admission application

NeuroTrauma Rehabilitation (NTR)

Locomotor Training Application Form
Neurotrauma Rehabilitation referral form

Osteoporosis and Bone Disease

Referral form osteoporosis and bone disease program

Pain Management Program

Pain Management Program Referral Form

Palliative Care

How to refer a patient to Palliative Care
Palliative Care referral form

Peripheral Nerve Clinic

Referral form: Peripheral Nerve Program

Primary Care Diabetes Support Program

Diabetic Foot Ulcer Referral Form
Primary Care Diabetes Support Program Referral Form
Primary Care Diabetes Support Program: What health care professionals can expect

Rheumatology Centre

Health Assessment Questionnaire (HAQ)
Interdisciplinary Vasculitis Clinic referral
New patient information form
Rheumatology follow-up form
Rheumatology referral form

Roth | McFarlane Hand and Upper Limb Centre (HULC)

Elective Referral Form Roth | McFarlane Hand and Upper Limb Centre
Emergency referral form Roth | McFarlane Hand and Upper Limb Clinic

Specialized Geriatric Services

Geriatric Ambulatory Access Team (GAAT) referral form
Specialized Geriatrics Parkwood Access Referral Form

Specialized Geriatric Services: Geriatric Rehabilitation Day Hospital

Geriatric Ambulatory Access Team (GAAT) referral form

Specialized Geriatric Services: Outpatient

Geriatric Ambulatory Access Team (GAAT) referral form

Spinal Cord Injury Rehabilitation

Parkwood Access Referral Form
Physiatry Consult Request Outpatient Spinal Cord Injury Program

Stroke/Neurological Rehabilitation Program

Parkwood Access Referral Form

Stroke: Comprehensive Outpatient Rehabilitation Program

CORP referral form

Surgery

Lithotripsy Manual Booking Form

Transitional and Lifelong Care

transitional and lifelong care program referral form (PDF)

Urology

PDAP referral form

Urology: Prostate Diagnostic Assessment Program (PDAP)

PDAP referral form

Wheelchair and Seating Program

Wheelchair Seating referral form
Wheelchair Seating referral process

Wound Care

Wound Care Referral Form