Referral forms

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All visitors and essential caregivers are screened prior to entry. Please review screening entry directions and our COVID-19 information.

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

Additional Services

Steele Street rehabilitation residence referral

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 - Guide for Referring Physicians
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 rehab referral form

Diabetes Education Centre

Diabetes Education Centre Referral Form

Driving Assessment Programs at Parkwood lnstitute

Driving Assessment referral form

EMG (Electromyography) Laboratory

EMG Referral Form

Heart Failure Clinic

Heart Failure clinic Referral Form

Ivey Eye Institute

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
Methacholine stop medication instructions
Pulmonary Function Lab Referral Form
Pulmonary function pre/post test medication to hold

Medical Imaging

General radiology referral form

Medical Imaging: Bone Mineral Density (BMD) Testing

General radiology 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: Nuclear Medicine

Nuclear medicine request form

Medical Imaging: PET (Positron Emission Tomography)/CT

PET/CT referral form

Medical Imaging: Radiology

General radiology referral form

Medical Imaging: Ultrasound

Ultrasound requisition

Medically Complex Patients

Complex continuing care admission application

Mental Health Care: Concurrent Disorders Services

Adult mental health ambulatory centralized access point

Mental Health Care: Steele Street Treatment and Rehabilitation Residential Program

Referral form for Steel Street Treatment and Rehabilitation Residential Program

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

Post-Acute COVID-19 Program

Post Acute COVID-19 Referral Form

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)

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

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

Stroke/Neurological Rehabilitation Program

Parkwood Access Referral Form

Stroke: Comprehensive Outpatient Rehabilitation Program

CORP referral form

Surgery

Lithotripsy referral form for physicians

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