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).
Medical imaging referral forms are below:
- Breast imaging, updated 2021
- CT, updated 2021
- MRI, updated 2021
- Nuclear medicine, updated 2021
- Special testing
- Ultrasound, updated 2021
- Ultrasound (emergency dept.)
- X-ray/Gastric Minor Fluoroscopic Special Procedures updated 2021
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.
Looking to refer a patient?
If you're a physician and would like to refer a patient to GRH, visit our referral page for referral forms and more information.Refer a patient/SCOPEFor pregnant patients without a family physician in the KW area and who require an obstetric provider for pregnancy care. Patients must have referral form submitted from KW area walk-in clinic or out of region obstetric provider.