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Referral and Consent Forms

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Home/Staff & Physicians/Physicians Resource Centre/Referral and Consent Forms

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Quick Links

  • Staff & Physicians Quick Link

List of consent and referral forms used by physicians.

  • Admission History and Physical
  • Arthritis Clinic Patient Referral Form
  • Breast Imaging - Needle Localization Core Biopsy Procedure
  • Breast Health Referral Form
  • Cardiovascular & Pulmonary Rehabilitation Referral Form
  • Consent for Disclosure of Personal Health Information
  • Consent to Treatment, Operative Procedure or Investigation
  • COVID-COLD & FLU Clinic Referral Form
  • CT Requisition
  • Domestic Abuse & Sexual Assault (DASA) Care Centre of York Region Patient Referral Form 
  • Diabetes Education Program Referral Form
  • Diabetes Education Program Self-Referral Form
  • Diagnostic Imaging Requisition
  • EEG LAB Outpatient Requisition
  • EMG Nerve Conduction Outpatient Requisition
  • FIT Positive Colonoscopy Referral
  • Genetics Cancer Questionnaire
  • Genetics Clinic family history questionnaire
  • Genetics Clinic Referral
  • Geriatric Outreach Services Referral
  • High Risk Pregnancy Referral
  • Home at Last Discharge Referral Form
  • House of Hearing Referral Form
  • Inpatient/Outpatient Thyroid Biospy Requisition
  • Inpatient/Outpatient Vascular Inventional Radiology Requisition
  • Mackenzie Health Referral to Emergency Department
  • Medical Urgent Care Clinic
  • Mental Health Adult Outpatient Referral Form
  • MRI Requisition
  • Neurosurgical Assessment Clinic Referral
  • Ontario MOHLTC IG Request Form - Non-Neurology Fillable
  • Ontario MOHLTC IG Request Form - Neurology Fillable
  • Orthopedic Consultation or Joint Replacement Referral
  • Pediatric Urgent Care Clinic Referral
  • Preoperative Breast Localization Booking
  • Pulmonary Function Requisition
  • Routine Pregnancy Screening Referral
  • Seniors Wellness Clinic Referral
  • Shaw Clinic Child & Family Services (ages 6 to 18 years)
  • TIA/Stroke/Neurology Clinic Community Referral
  • Transfusion and Alternative Options/Release from Liability for Jehovah’s Witness
  • Transfusion Medicine - Investigation of a Transfusion Reaction
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© 2017 Mackenzie Health
10 Trench St., Richmond Hill, ON
L4C 4Z3
Local to Richmond Hill: 905-883-1212
Local to Vaughan: 905-832-4554
TTY Service: 905-883-2123

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    • Continuing Care and Rehabilitation
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