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 |
| South West | Grey Bruce Health Services | Thoracic |
| South West | Grey Bruce Health Services | Prostate |
| South West | London Health Sciences | Anal, Colon, Lung, Rectal (Oncology Patient Navigation Program) |
| South West | London Health Sciences | Colorectal |
| South West | London Health Sciences | Hepato/Pancreatic/Biliary (HPB) |
| 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 |