Health Care Provider Forms
Child and Adolescent Psychiatry Forms
Child and Adolescent Psychiatry referral form, Eating Disorder Program Referral Form, Regional Mental Health Central Referral Form, Pediatric Acute Mental Health Admission Referral Form
Diagnostic Services Forms
Diagnostic Imaging (ECG/EEG, ECHO, Mammography, MRI, Ultrasound & X-Ray) and Laboratory Services referral, requisitions, information and other forms.
Medical Clinic/Program Forms
Anticoagulation, Chemotherapy, Clinical Nutrition, Cystoscopy, Endoscopy, Kidney Care, Ophthalmology, Orhtopedic, Pacemaker, Pain Management, Pulmonary Function, Stroke Prevention, Women’s, Wound Clinics & Telemedicine services referral and information forms.
Mental Health & Addictions Forms
Mental Health and Addiction services (Regional Outreach & Seniors and Regional Specialized Program) referral and admission forms.
Other Forms
All other forms can be found in this section: Consent to Treatment, Clinic Fee Schedule, Bed Allocation Form, Dear Patient – Influenza & Faxing Order Form (Orders Faxed from Physician’s Offices).
Rehabilitation (Inpatient & Outpatient) Forms
Rehabilitation services (Occupational Therapy, Physiotherapy, SportMED+, Rehabilitation & Speech Language Pathology) referral forms and medical directives.
Surgical Services Forms
Surgical services questionnaires, referral, booking and information forms (Inpatient, Outpatient, Operating Room, PACU, Pre-Admission, Urodynamic & Vasectomy Clinics).
Women & Children Forms
Birthing, Gynecology, Neonatal Intensive Care, Pediatrics, Respiratory Syncytial Virus and Social Services screening, information and pre-admission forms.
North Bay
50 College Drive,
P.O. Box 2500
North Bay, ON
P1B 5A4
Tel: 705-474-8600
Sudbury
680 Kirkwood Drive,
Sudbury, ON
P3E 1X3
Tel: 705-675-9193
Fax: 705-675-6817
