Health Care Provider Forms
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
