Referral and Consent Forms
List of consent and referral forms used by physicians.
Mackenzie Health is now accepting electronic referrals for Diagnostic Imaging through Ocean eReferral. Sign up at: www.ehealthce.ca/eReferral
- Acute Respiratory Clinic Referral Form
- Admission History and Physical
- Arthritis Clinic Patient Referral Form
- Attending Physician's Statement
- Breast Imaging - Needle Localization Core Biopsy Procedure
- Breast Health Clinic Referral Form
- Cardiovascular, Pulmonary and Stroke Rehabilitation Referral Form
- Clinical Assessment Centre
- Consent for Disclosure of Personal Health Information
- Consent to Treatment, Operative Procedure or Investigation
- CT Coronary Angiography Requisition
- CT Requisition
- Domestic Abuse and Sexual Assault (DASA) Care Centre of York Region Patient Referral Form
- Diabetes Education Program Referral Form
- Diabetes Education Program Self-Referral Form
- Diabetes Education Program Referral – Woman and Child Program (Pregnancy)
- Diagnostic Imaging Requisition
- Echocardiogram Requisition
- EEG LAB Outpatient Requisition
- EMG Nerve Conduction Outpatient Requisition
- FIT Positive Colonoscopy Referral
- Fracture/Plastic Surgery Clinical Referral Form
- Genetics Cancer Questionnaire
- Genetics Clinic family history questionnaire
- Genetics Clinic Referral
- High Risk Pregnancy Referral
- Home at Last Discharge Referral Form
- Interventional Radiology Requisition
- Mackenzie Health Referral to Emergency Department
- Mackenzie Health Children's Clinic - Pediatric Referral Form
- Medical Urgent Care Clinic
- Mental Health Adult Outpatient Referral Form
- MRI Requisition
- Oncology External Referral Form
- Ontario MOHLTC IG Request Form - Non-Neurology Fillable
- Ontario MOHLTC IG Request Form - Neurology Fillable
- Orthopedic Consultation or Joint Replacement Referral
- Ultrasound Guided Thyroid FNA/Lymph Node Biopsy Requisition
- Pediatric Urgent Care Clinic Referral
- Preoperative Breast Localization Booking
- Pulmonary Function Requisition
- Rapid Assessment Cardiac Clinic Referral
- Routine Pregnancy Screening Referral
- Seniors and Compassionate Care (Outpatient) 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
Note: If you are a community provider and would like to receive your patient’s medical records electronically through Health Report Manager (HRM), or if you have recently moved or have new contact information, please complete our Provider Change Form.