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.
| REFERRAL FORM | LOCATION | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| New Patient Referral Form | Grand River Regional Cancer Centre | - Pathology reports documenting cancer diagnosis - a consultation letter highlighting presenting signs, symptoms and findings - Signature of referring physician |
| Waterloo Wellington Hospitals Breast Imaging Requisition (Screening Referral or *Diagnostic Referral) | - Cambridge Memorial Hospital - Guelph General Hospital* - Grand River Hospital, Freeport Campus* (Waterloo Wellington Breast Centre) - Groves Memorial Community Hospital | Exam Information |
| Community Services/Palliative Care *Coming Soon* | ||
| Genetic Counselling | Grand River Regional Cancer Centre | - Patient consent for genetics referral - Completed Family History Questionnaire |
| Lung Diagnostic Assessment Program | Grand River Regional Cancer Centre | - CT chest report - Abnormal chest x-ray report |
| Malignant Pleural Effusion Clinic | Grand River Regional Cancer Centre | |
| Waterloo Wellington Coordinated Colonoscopy Assess Program | Grand River Regional Cancer Centre | |
| Multidisciplinary Case Conferences | Grand River Regional Cancer Centre | - Imaging and pathology information and booking dates - Signature |
| High Risk Ontario Breast Screening Program | Grand River Regional Cancer Centre | - Genetic Assessment required |
For more information contact our New Patient Referrals (NPR) office:
519-749-4370 extension 5720
If you would like to see referral information for other Grand River Hospital programs/services please visit our hospital wide referral page.
