Updated on: Sep 12, 2024
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.
Hospital Programs
| REFERRAL FORM | LOCATION | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| Waterloo Wellington Regional Cancer Program: New Patient Referral Form Cambridge New Patient Referral Form *Coming Soon* | Grand River Regional Cancer Centre Cambridge Memorial Hospital | - 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 |
| Palliative Care: Palliative Care Inpatient/Hospice Services | - Grand River Hospital - Groves Memorial Hospital - St. Joseph's Health Centre Guelph - Lisaard & Innisfree Hospice - Hospice Wellington - Hospice Waterloo Region | - Isolation issues - COVID-19 Status - Outstanding medical investigations |
| Genetic Counselling | Grand River Regional Cancer Centre | - Patient consent for genetics referral
- Completed Family History Questionnaire |
| Malignant Pleural Effusion Clinic | Grand River Regional Cancer Centre | n/a |
| Multidisciplinary Case Conferences | Grand River Regional Cancer Centre | - Imaging and pathology information and booking dates - Signature |
Screening & Assessment Programs
| DISEASE SITE | REFERRAL FORM | LOCATION | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| Breast | High Risk Ontario Breast Screening Program | Grand River Regional Cancer Centre | - Genetic Assessment required |
| Cervical | COMING SOON! Waterloo Wellington High-Grade Colposcopy Central Referral Program (KW only) | ||
| Colorectal | Waterloo Wellington Coordinated Colonoscopy Assess Program | Grand River Regional Cancer Centre | n/a |
| Lung | Lung Diagnostic Assessment Program | Grand River Regional Cancer Centre | - CT chest report - Abnormal chest x-ray report |
Community Care
| REFERRAL FORM | LOCATION | COMPLETED REFERRAL MUST ALSO INCLUDE: |
| Waterloo Wellington LHIN Services | Waterloo Wellington Region | n/a |
| Community Palliative Care (WWLHIN) Request for Hospice Palliative Care Services | Waterloo Wellington Region | - Community MRP information - Indicate Palliative Physician role |