Updated on: Oct 01, 2025
Referral Forms
You can refer a patient to a service or program within the Waterloo Wellington Regional Cancer Program by filling out a referral form. Most forms below will open in the same window.
Hospital Programs
| REFERRAL FORM | LOCATION | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| Waterloo Wellington Regional Cancer Program: Grand River Regional Cancer Centre New Patient Referral Form Cambridge Memorial Hospital Outpatient Oncology Program New Patient Referral Form | Grand River Regional Cancer Centre Referral Options: 1) Fax Referral Form CMH Outpatient Oncology Program Referral options: 1) Ocean eReferrals 2) Fax Referral Form If using Ocean: - Login to your Ocean account - Search the Ocean Healthmap for "Cambridge Memorial Hospital Outpatient Oncology Program" - Add to your favourites list for quick access - Complete and submit your eReferral | - Pathology reports documenting cancer diagnosis
- A consultation letter highlighting presenting signs, symptoms and findings - Signature of referring physician or Nurse Practitioner |
| Waterloo Wellington Hospitals Breast Imaging Requisition (Screening Referral or *Diagnostic Referral) | - Cambridge Memorial Hospital
- Guelph General Hospital* - Waterloo Regional Health Network, Freeport Campus* (Waterloo Wellington Breast Centre) - Groves Memorial Community Hospital | Exam Information |
| Palliative Care: Palliative Care Inpatient/Hospice Services | - Waterloo Regional Health Network - Groves Memorial Hospital - St. Joseph's Health Centre Guelph - Lisaard & Innisfree Hospice - Hospice Wellington - Hospice Waterloo Region | - Isolation issues - COVID-19 Status - Outstanding medical investigations |
| Genetic Counselling Referral Form (including family history questionnaire) See "Screening and Assessment Programs" below for the high risk OBSP referral form. | WRHN Cancer Centre | - Patient consent for genetics referral
- Completed Family History Questionnaire |
| Malignant Pleural Effusion Clinic | WRHN Cancer Centre | n/a |
| Multidisciplinary Case Conferences | WRHN Cancer Centre | - Imaging and pathology information and booking dates
- Signature |
Screening & Assessment Programs
| DISEASE SITE | REFERRAL FORM | LOCATION OF SERVICE | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| Breast | High Risk Ontario Breast Screening Program | Waterloo Regional Health Network - Freeport Campus | - Most recent mammogram report (if available) - Previous genetic testing or risk assessment results (Required for category A and if available, include for category B) |
| Cervical | Waterloo Wellington High-Grade Colposcopy Central Referral Program | Regional Colposcopists across Waterloo Wellington | n/a |
| Colorectal | Waterloo Wellington Coordinated Colonoscopy Assess Program | Regional GI Endoscopists or Colorectal Surgeons | n/a |
| Lung | Lung Diagnostic Assessment Program | WRHN Cancer Centre | - CT chest report - Abnormal chest x-ray report |
Community Care
| REFERRAL FORM | LOCATION | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| Waterloo Wellington LHIN Services | Waterloo Wellington Region | n/a |
| Community Palliative Care (WWLHIN) Request for Hospice Palliative Care Services | Waterloo Wellington Region | - Community MRP information - Indicate Palliative Physician role |