Refer a patient/SCOPE

Waterloo Regional Health Network (WRHN) has 15 clinical programs and services to care for the members of our community.

Below is a list of referral forms for you to refer patients for care. These forms must be completed by a healthcare professional (i.e. doctor).

If you’re a member of the community and feel that you should be referred for one of these services, please speak with your healthcare provider.

Referral forms (PDF format unless stated otherwise)

Children's Program

• Outpatient pediatric nutrition referral form
• Outpatient children and adolescent eating disorder program referral form

Childbirth Program

• Early Pregnancy Assessment Clinic
• OB Roster referral form

Complex Continuing Care and Rehabilitation

• Complex continuing care and rehabilitation: Inpatient application form
• Complex continuing care: Neurobehavioural unit/GAU referral form
• Complex continuing care and rehabilitation: Change in status update
• Complex continuing care: Letter of understanding
• NBU/GAU- letter of understanding
• Pain Management Centre, Freeport Campus: patient referral form for provider use, updated April 2019
• Rehabilitation consent: Letter of understanding
• Rehabilitation: pulmonary rehabilitation physician referral- outpatient, updated 2024
• Activation/Restoration: Letter of understanding

Communication technology clinic:

• Communication technology clinic: referral package, updated October 2 2017

EMG Testing

• EMG: WRHN @ Midtown
• EMG: WRHN @ Chicopee (updated 2025)

Medical Imaging

• Breast imaging, updated 2025
• MRI, updated 2025
• Nuclear medicine, updated 2025
• Cardio Respiratory & Electrodiagnostic Services (formerly Special Testing), updated 2023
• Ultrasound, updated 2025
• Ultrasound (emergency dept.)
• X-ray/Gastric Minor Fluoroscopic Special Procedures, updated 2025
• Bone Mineral Density, updates 2025
• Provider Information Form, updated 2025

Medicine

• Community referral to internal medicine (GIMRAC and non-malignant hematology clinic), updated October 2020
• Waterloo Wellington diabetes central intake (this will open an on-line referral form in a new tab)

Mental Health and Addictions

• Short-Term Psychiatry Clinic (STP)referral form updated July 2024
• Psychiatric Consultation Clinic (PCC)referral form updated August 2024
• Child and adolescent outpatient referral form updated May 2018
• Dual Diagnosis Clinic referral form updated 2023
  • Dual Diagnosis Clinic referral checklist
• Specialized mental health adult referral form
• Specialized mental health seniors referral form

Neuro Rehabilitation Clinic

• Neuro rehabilitation clinic: Neuro Rehab Clinic Referral Form (updated 2025)
• Neuro rehabilitation physiatry: Neuro rehab physiatry referral form (updated 2024)
• Outpatient swallowing clinic: Swallowing Referral Form (updated 2025)

Outpatient Procedures

• IV iron sucrose physician package updated July 2020

Palliative Care

• Palliative care/hospice: Referral form [redirects to Home and Community Care Support Services - Waterloo Wellington]
• Notification of CCC, rehab or residential hospice bed vacancy: Notification of bed vacancy
• Status update/program transfer requests form
• CCC palliative and residential hospice program criteria
• WW palliative care units - description of services
• Coordinated bed access for palliative care - process update

Prosthetic and Orthotic Clinic

• Prosthetic and orthotic clinic: Prosthetic and Orthotic Referral Form (updated 2024)

Renal (Kidney) Care

• Regional renal program referral form
• Identification, detection and management of CKC in primary care

Stroke Care

• Secondary stroke prevention clinic referral form

Surgery

• Regional orthopedic referral form (this will open an on-line referral form in a new tab)

Transition Care Unit - Referral Form

WRHN Cancer Centre / Waterloo Wellington Regional Cancer Program

If you would like to refer a new patient to the WRHN Cancer Centre/Waterloo Wellington Regional Cancer Program diagnostic assessment programs or would like more information, contact our new patient referrals office at 519-749-4370 extension 5720.

• New patient referral form
• Waterloo Wellington Breast Centre, updated October, 2024
• Genetic Counselling
• Ontario High-Risk Breast Screening Program
• Lung diagnostic assessment program
• Malignant pleural effusion clinic
• Multidisciplinary cancer conference
• Palliative care
• Waterloo Wellington Coordinated Colonoscopy Access Program
• Please note that our lymphedema outpatient clinic has closed.

Preparing your patients

Please share the following with your patients before their visit to WRHN.

Please inform your patients:

• who their appointment is with;
• the date of their appointment;
• what time they need to arrive for their appointment; and
• where campus their appointment is at.

Please advise patients to bring the following items to their appointment:

• Health card;
• A list of medications they are currently taking;
• Test results from another doctor or hospital (if applicable);
• A family member or support person; and
• A list of questions that they wish to have answered during their visit.

Sending a patient to Waterloo Regional Health Network from another facility

This information is intended for other facilities transferring a patient to Waterloo Regional Health Network through the bed allocation department.

Guidelines for transfer

Transfer of Information (TOI) form

International patient referrals

Non-Ontario residents and residents without Ontario health insurance are considered self-pay patients. Self-pay patients are required to meet eligibility criteria, complete self-pay financial forms and follow a standard admitting process to be considered to receive care at WRHN.

Our patient access and flow department manages all international referrals/requests and supports our patients and families through the application process and delivery of care. All applications are reviewed by our healthcare professionals to determine if care can be provided at WRHN.

For more information regarding an international patient referral, please contact 519-749-4300 extension 4434.