Standard Diagnostic Imaging Requisition Forms are now in effect.

The Diagnostic Imaging Integrated Program Council, in partnership with the System Coordinated Access Program (SCA) have developed standardized regional diagnostic imaging outpatient requisitions. This means that all hospitals within Waterloo Wellington Region are now accepting the same forms for outpatient DI requisitions (i.e. for MRI, CT, etc.).

The standardized regional forms can be sent by fax, electronically (i.e. EMR custom form) or by an electronic referral solution (eReferral).

To add electronic referral to your practice please click the link here or email

Medical imaging referral forms are below:

All referral forms can be found on our refer a patient page.

Please make sure the requisition includes the following information:

  • Patient's name;
  • Patient’s health card number;
  • Date of birth;
  • Ordering doctor's name and those who need a copy;
  • Specific test requested;
  • Pertinent information; and
  • Reason for the test.