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Diagnostic Assessment Program Referral Forms

These forms are meant for healthcare providers to download and use to refer patients to Diagnostic Assessment Programs in Ontario. Please direct all enquiries and completed forms directly to the appropriate Diagnostic Assessment Program.

REGION/LHIN FACILITY REFERRAL FORM
Erie St. Clair Windsor Regional Hospital Colorectal, Lung, Prostate
South West Grey Bruce Health Services Thoracic
South West Grey Bruce Health Services Prostate
South West London Health Sciences Thoracic
South West London Health Sciences Colorectal
South West London Health Sciences Hepato/Pancreatic/Biliary (HPB)
South West London Health Sciences Rectal
South West St. Joseph’s Health Care London Colorectal
South West St. Joseph’s Health Care London Prostate
Waterloo Wellington Grand River Hospital Thoracic
Waterloo Wellington Waterloo Wellington Regional Colonoscopy Network Colonoscopy
Waterloo Wellington Waterloo Wellington Lung
Hamilton Niagara Haldimand Brant St. Joseph's Hamilton, Niagara Health System and Brant Community Health System General Lung, Esophageal
Mississauga Halton/Central West Trillium Health Partners, Mississauga Halton/Central West Regional Cancer Program Breast
Mississauga Halton/Central West Trillium Health Partners, Mississauga Halton/Central West Regional Cancer Program Hepato-Pancreatic-Biliary
Mississauga Halton/Central West Trillium Health Partners, Mississauga Halton/Central West Regional Cancer Program Thoracic
Mississauga Halton/Central West Trillium Health Partners, Mississauga Halton/Central West Regional Cancer Program Rectal
Mississauga Halton/Central West William Osler Health System Thoracic
Toronto Central (South) Mount Sinai Hospital Colorectal
Toronto Central (South) St. Michael's Hospital Colorectal
Toronto Central (South) University Health Network Breast
Toronto Central (South) University Health Network Colorectal
Toronto Central (South) University Health Network Thoracic
Toronto Central (North) Sunnybrook Health Sciences Centre Colorectal Lung
Toronto Central (North) Michael Garron Hospital Lung
Toronto Central (North) Michael Garron Hospital Thyroid
Toronto Central (North) Michael Garron Hospital Breast
Central North York General Hospital Prostate
Central Southlake Regional Health Centre Breast
Central Southlake Regional Health Centre Lung
Central Southlake Regional Health Centre Colorectal
Central Southlake Regional Health Centre Prostate
Central East Lakeridge Health, Peterborough Regional Health Centre and Rouge Valley Centenary Thoracic
Central East Lakeridge Health Prostate
Central East Lakeridge Health Colorectal
Central East Lakeridge Health Gynecology
South East Kingston General Hospital Lung
South East Hotel Dieu, Kingston Colorectal
Champlain The Ottawa Hospital Cancer Assessment Clinic and Ottawa Regional Women's Breast Health Centre Breast, Lung, Colorectal, Prostate
North Simcoe Muskoka Royal Victoria Hospital Thoracic, Rectal
North East Health Sciences North Colonoscopy
North East North East Cancer Centre Lung
North East Sault Area Hospital (Algoma only) Lung
North West Thunder Bay Regional Health Sciences Centre Lung
North West Thunder Bay Regional Health Sciences Centre Colonoscopy