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
- 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 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 & 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 & Child Program (Pregnancy)
- Diagnostic Imaging 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
- Outpatient Thyroid Biopsy Requisition
- Pediatric Urgent Care Clinic Referral
- Preoperative Breast Localization Booking
- Pulmonary Function Requisition
- Rapid Assessment Cardiac Clinic Referral
- Routine Pregnancy Screening Referral
- Seniors Services (outpatients) 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