Patient Referral Forms and Requisitions

This page is for healthcare professionals only.  To access many of our services, patients must provide a physician referral or requisition form.  Please speak with your healthcare provider if you have any questions or concerns.

The forms attached below are posted as Adobe PDF files and you require Adobe Acrobat in order to view these forms. In some cases you may be able to fill the form in online and then print, however, you may have to print the form first then fill it in and fax to the number on the form.

Please ensure that you are faxing all forms to the correct fax number.

Ambulatory Care

Consent form

Consent to an Operative and/or Investigative Procedure and Transfusion

Order Sets

• IV Iron order set
  Guidelines for Iron Infusion use in Adults
• Peripherally Inserted Central Catheter (PICC) order set
• Therapeutic Phlebotomy order set

Referrals

• Medical Day Clinic referral form
• Stroke Prevention Clinic (SPC) referral form

Cardiovascular requisitions 

Cardiovascular Services Requisition

Colonoscopy referrals 

Fecal Immunochemical Test (FIT) or Fecal Occult Blood Test (FOBT) 

Diagnostic Imaging requisitions 

For more information, please visit Diagnostic Imaging.

• Consent Form
• CT scan requisition
  CT scan patient information sheet
• CT colonography (CTC) requisition
  CT colonography patient preparation information
• General radiology - fluoro requisition
  Bone mineral density - requisition/questionnaire
• Mammography requisition
  Mammography patient information sheet
• Ultrasound - echocardiography requisition
  Ultrasound patient preparation information

Respiratory Therapy

Respiratory Therapy Services Pulmonary Function requisition

If you do not see the form you are looking for, please email us to have it added.