Refer a patient

• Grand River Hospital (GRH) is the largest hospital in the region. We offer 15 clinical programs and services to care for the members of our community.

Below is a list of referral forms for you to refer your patients for care at GRH. These forms must be completed by a health care 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 health care provider.

Referral forms

Unless otherwise stated, referral forms are in PDF format.

Children's Program

• Outpatient pediatric nutrition referral form

Childbirth Program

• Early pregnancy assessment clinic

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: Confirmation of medical stability
• 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 June 2018
• Activation/Restoration: Letter of understanding
• Complex continuing care and rehabilitation: Notification of bed vacancy

Communication technology clinic:

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

Neuro Rehabilitation Clinic:

• Neuro rehabilitation and geriatric rehabilitation clinic: Referral form
• Outpatient swallowing clinic: Swallowing referral form

Prosthetic and Orthotic Clinic:

• Prosthetic and orthotic clinic: Referral form

Palliative Care

• Palliative care/hospice: Referral form
• 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

EMG Testing

• EMG/evoked potential: KW Campus
• EMG: Freeport Campus, updated June 2 2017

Medical Imaging

• Biopsy
• Breast imaging, updated June 27 2018
• CT, updated June 28 2018
• MRI
• Nuclear medicine
• Special testing
• Ultrasound
• Ultrasound (emergency dept.)
• X-ray/Gastric Minor Fluoroscopic Special Procedures

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

• Adult outpatient referral form updated January 2017
• Child and adolescent outpatient referral form updated May 2018
• Specialized mental health adult referral form
• Specialized mental health seniors referral form

Outpatient Procedures

• IV iron sucrose physician package updated July 2020

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)

Grand River Regional Cancer Centre

If you would like to refer a new patient to the Grand River Regional 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
• Breast diagnostic assessment program (Waterloo Wellington Breast Centre), updated June 27 2018
• Colorectal/GI diagnostic assessment program
• Genetics counselling
• Lung diagnostic assessment program
• Malignant pleural effusion clinic
• Multidisciplinary cancer conference
• OBSP high risk breast screening program
  • Family health questionnaire
• Palliative care
• Regional Colonoscopy Network
• Registered nurse flexible sigmoidoscopy program

Preparing your patients

Please ensure you prepare your patients for their visit to GRH. Coming prepared and knowing where to go will help ease the anxiety many patients feel when coming to the hospital and ensure they arrive on time.

Please inform your patients:

• who their appointment is with;
• the date of their appointment;
• what time they need to arrive for their appointment;
• where their appointment is; and
• how to get to their appointment (directions, parking, etc).

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

• Their 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.

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 GRH.

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 health care professionals to determine if care can be provided at GRH.

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