Patient Referrals & Requisitions
This page is intended for healthcare professionals only. Patients who have questions about a referral or requisition should speak with their physician, nurse practitioner, or healthcare provider.
Referral forms and requisitions are provided in PDF format. Some forms can be completed electronically before printing, while others may need to be printed and completed manually. Please follow the instructions provided on each form and ensure it is submitted to the correct fax number.
Please ensure that you are faxing all forms to the correct fax number.
Diagnostic Imaging Requisitions
For more information, please visit Diagnostic Imaging and Cardiovascular Services.
- CT scan requisition
- CT colonography (CTC) requisition
- Fluoroscopy Requisition
- General Radiology Requisition
- Bone mineral density - requisition/questionnaire
- Mammography, Diagnostic, and Screening Requisition
- Ontario Breast Screening Program Guidelines (Note: Brockville General is an average risk screening centre.)
- Ontario Breast Screening Program self-referral form
- MRI requisition form
- Ultrasound requisition
- Echocardiography/Cardiovascular Services requisition