Standardized eReferral Form: Medical Imaging
This form demonstrates the content of a standardized eReferral. Final design may differ.
Please provide your feedback in the form on the right-hand side
The form is designed to be viewed on a computer.
For more information about specific sections on the form, please click the yellow “Notes” buttons on the left hand side of the page.
Patient Information
Surname:
First:
DOB:
Gender:
HN:
Mobile #:
Home #:
Business #:
Email:
Address:
* Indicates a required field
[Optional] Additional Patient Information
Sex assigned at birth:
Pronouns:
Other pronouns:*
Preferred language:
Specify: *
Best method of contact:
Alternate Contact Phone #:
Name:*
Relationship:
Is Alternate Contact the appointment booking contact?
Do not speak with:
Details of special considerations: *
Name(s):*
Contact information:*
Exam Requests
Triage Considerations
Requested Triage Priority*
Reason for urgent triage: *
Notes
Triage Urgency
- A referrer can select “Urgent” for referral triage and provide a “Reason for Urgent Triage. “Routine” is the default selection.
- It’s expected that the receiver will ultimately decide the Priority of the referral based on the Reason for Exam.
X
Clinical History / Indication*
Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable) *
Additional relevant information (e.g. request specific views)
Select CT Exam/Region(s) of Interest:*
Head: Specific area of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Head region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Neck: Specific area of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Neck region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Spine: Specific area of interest *
Low Back Pain - Quality Standards
?
Low Back Pain - Quality Standards
People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease.
Red flag signs or symptoms include:
- Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome
- Infection: fever, history of IV drug use, immunosuppression
- Fracture: trauma, osteoporosis risk/fragility fracture
- Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue
- Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain.
Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019.
X
Specify:*
Thorax: Specific area/exam of interest (optional)
?
Instruction
Optional selections for a more specific anatomy of interest within the Thorax region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Specify:*
Abdomen/Pelvis: Specific area/exam of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Abdomen Pelvis region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Musculoskeletal: Specific area of interest *
*
*
*
*
*
*
*
*
*
*
*
*
Specify:*
Osteoarthritis - Quality Standards
?
X
Osteoarthritis - Quality Standards
People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis
Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints.
Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present).
Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024.
Angiography Arterial: Specific area of interest *
Specify:*
Angiography Venous: Specific area of interest *
Specify:*
Cardiac: Specific*
Specify area of interest
Specify:
Notes
Select Exam/Region(s) of Interest:
- The exam performed is determined by the receiving site based on the "Reason for Exam" and "Region(s) of Interest" selected.
- This list serves two main purposes:
- To assist with triage and routing on the receiver’s end.
- To provide indication-specific clinical guidance and questions to aid in triage (when applicable).
- This list covers the most common Regions of Interest, but it is not exhaustive. An “Other” option is included for additional selections.
- Most Regions of Interest can be selected as a general area (e.g., Head and Thorax). Some require a more specific selection (e.g., Cervical Spine within the Spine category). This is indicated by the required field setting (*) under the Spine category.
X
?
Instruction
Selection(s) can be for a general area of interest or a more specific anatomy.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Notes
Select Exam/Region(s) of Interest
- The exam performed is determined by the receiving site based on the "Reason for Exam" and "Region(s) of Interest" selected.
- This list serves two main purposes:
- To assist with triage and routing on the receiver’s end.
- To provide indication-specific clinical guidance and questions to aid in triage (when applicable).
- This list covers the most common Regions of Interest, but it is not exhaustive. An “Other” option is included for additional selections.
- Most Regions of Interest can be selected as a general area (e.g., Head and Thorax). Some require a more specific selection (e.g., Cervical Spine within the Spine category). This is indicated by the required field setting (*) under the Spine category.
X
Instruction
Selection(s) can be for a general area of interest or a more specific anatomy.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Select MRI Exam/Region(s) of Interest:*
Head: Specific area of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Head region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Neck: Specific area of interest (optional)
*
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Neck region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Spine: Specific area of interest *
Low Back Pain - Quality Standards
?
X
Low Back Pain - Quality Standards
People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease.
Red flag signs or symptoms include:
- Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome
- Infection: fever, history of IV drug use, immunosuppression
- Fracture: trauma, osteoporosis risk/fragility fracture
- Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue
- Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain.
Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019.
Specify:*
Thorax: Specific area of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Thorax region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Abdomen: Specific area of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Abdomen region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Pelvis: Specific area of interest (optional)
Specify:*
?
Instruction
Optional selections for a more specific anatomy of interest within the Pelvis region.
Please note the exam performed is determined by the referral receiving site based on the reason for exam.
X
Musculoskeletal: Specific area of interest *
*
*
*
*
*
*
*
Left finger(s):*
Right finger(s):*
Hip Pain (Osteoarthritis) - Imaging Appropriateness
?
Instruction
MRI is NOT routinely indicated Avoid advanced imaging (MRI) in arthritic joints.
X
*
*
*
*
*
*
*
Left toe(s):*
Right toe(s):*
Specify:*
Osteoarthritis - Quality Standards
?
X
Osteoarthritis - Quality Standards
MRI is NOT routinely indicated. Avoid advanced imaging (MRI) in arthritic joints.
People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis
Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints.
Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present).
Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024.
Angiography Arterial: Specific area of interest *
Specify:*
Angiography Venous: Specific area of interest *
Specify:*
Breast: Specific Area of Interest*
*
*
Specify:*
Specify:
Notes
Select Exam/Region(s) of Interest:
- The exam performed is determined by the receiving site based on the "Reason for Exam" and "Region(s) of Interest" selected.
- This list serves two main purposes:
- To assist with triage and routing on the receiver’s end.
- To provide indication-specific clinical guidance and questions to aid in triage (when applicable).
- This list covers the most common Regions of Interest, but it is not exhaustive. An “Other” option is included for additional selections.
- Most Regions of Interest can be selected as a general area (e.g., Head and Thorax). Some require a more specific selection (e.g., Cervical Spine within the Spine category). This is indicated by the required field setting (*) under the Spine category.
X
?
Notes
Select Exam/Region(s) of Interest
- The exam performed is determined by the receiving site based on the "Reason for Exam" and "Region(s) of Interest" selected.
- This list serves two main purposes:
- To assist with triage and routing on the receiver’s end.
- To provide indication-specific clinical guidance and questions to aid in triage (when applicable).
- This list covers the most common Regions of Interest, but it is not exhaustive. An “Other” option is included for additional selections.
- Most Regions of Interest can be selected as a general area (e.g., Head and Thorax). Some require a more specific selection (e.g., Cervical Spine within the Spine category). This is indicated by the required field setting (*) under the Spine category.
X
MRI Safety Screening*
To prevent delays in scheduling, please provide all relevant information.
Attach x-ray reports post injury, if available
What implants does the patient have: *
Specify:
Implant details including make, model, institution and date (if known).
Attach relevant report if available.
What implants does the patient have: *
Specify:
Implant details including make, model, institution and date (if known).
Attach relevant report if available.
Select X-Ray Exam / Region(s) of Interest:*
Chest exams:*
*
Specify:*
Abdomen exams:*
Specify:*
Spine exams:*
Low Back Pain - Quality Standards
?
X
Low Back Pain - Quality Standards
People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease.
Red flag signs or symptoms include:
- Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome
- Infection: fever, history of IV drug use, immunosuppression
- Fracture: trauma, osteoporosis risk/fragility fracture
- Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue
- Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain.
Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019.
Scoliosis spine views: *
Specify:*
Head and Neck exams:*
Orbits exams:*
Sinus x-rays are not covered by OHIP and are not recommended in adults with sinus disease.
Specify:*
Upper Extremity exams:*
*
*
*
Specify:*
*
*
*
*
*
*
*
*
Left finger(s):*
Right finger(s):*
Specify:*
Osteoarthritis - Quality Standards
?
X
Osteoarthritis - Quality Standards
People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis
For X-Ray Knee: weight-bearing images are required within 6-month period prior to the patient’s first appointment with a surgeon.
For X-Ray Hip or Shoulder: Plain radiographs (non-weight bearing for hip, and AP view for shoulder) are required within the 6-month period prior to the patient’s first appointment with a surgeon.
Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints.
Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present).
Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024.
Lower Extremity exams:*
Hip Pain (Osteoarthritis) - Imaging Recommendation
?
Instruction
X-ray is NOT routinely indicated
Radiographs are not required to make a diagnosis and do not alter management in patients with less severe degenerative disease.
X-ray may be indicated for the below presentations:
- Possibly valuable for baseline.
- If patient does not demonstrate good response to adequate attempt of conservative management (~6-12 weeks).
Consider X-ray (AP pelvis, AP and Lateral of affected hip) to assess progression, rule out other pathology and help guide management.
X
*
Hip Pain (Osteoarthritis) - Imaging Recommendation
?
Instruction
X-ray is NOT routinely indicated
Radiographs are not required to make a diagnosis and do not alter management in patients with less severe degenerative disease.
X-ray may be indicated for the below presentations:
- Possibly valuable for baseline.
- If patient does not demonstrate good response to adequate attempt of conservative management (~6-12 weeks).
Consider X-ray (AP pelvis, AP and Lateral of affected hip) to assess progression, rule out other pathology and help guide management.
X
*
*
Knee Pain (Osteoarthritis) - Imaging Recommendation
?
Instruction
X-ray is NOT routinely indicated
Radiographs are not required to make a diagnosis and do not alter management in patients with less severe degenerative disease.
X-ray may be indicated for the below presentations:
- Possibly valuable for baseline.
- If patient does not demonstrate good response to adequate attempt of conservative management (~6-12 weeks).
Please ensure that this test is appropriately indicated before ordering by reviewing the Imaging Decision Support & Resources
Based on the Diagnostic Imaging Appropriateness Project (2015), a collaborative effort between the Joint Department of Medical Imaging (University Health Network, Sinai Health Systems, Women’s College Hospital), Health Quality Ontario, and the Ministry of Health and Long-Term Care.
X
*
*
*
*
*
*
Left toes:*
Right toes:*
Specify:*
Osteoarthritis - Quality Standards
?
X
Osteoarthritis - Quality Standards
X-ray is NOT routinely indicated
People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis
For X-Ray Knee: weight-bearing images are required within 6-month period prior to the patient’s first appointment with a surgeon.
For X-Ray Hip or Shoulder: Plain radiographs (non-weight bearing for hip, and AP view for shoulder) are required within the 6-month period prior to the patient’s first appointment with a surgeon.
Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints.
Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritis, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present).
Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024.
Survey:*
Specify:*
Gastric and fluoroscopic imaging exams:*
Gastrointestinal tract exams:
Specify:*
*
Specify:*
Specify:*
Specify:*
Specify:*
Notes
Select Exam/Region(s) of Interest
- This list covers the most common exams, but it is not exhaustive. An “Other” option is included for additional selections.
X
Select Ultrasound Exam / Region(s) of Interest:*
Abdomen and Pelvis:*
*
Male Pelvis (Including Prostate): *
*
Specify:*
Gynecological:*
Specify:*
Obstetrical*
Specify:*
Female pelvis related additional requests:
Number of babies:*
Specify:*
High-Risk:*
Specify:*
Pregnancy type:*
Neonatal and paediatric:*
Specify:*
Musculoskeletal:*
*
*
*
Specify:
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Left digit(s):*
Right digit)(s:*
*
Left digit(s):*
Right digit)(s:*
Specify:*
Specify:*
Vascular:*
*
*
*
*
*
Specify extremity:*
Specify:
*
Specify extremity:*
Specify:*
Head and Neck:*
Specify:*
Specify:*
Specify:*
*
*
Specify:*
Miscellaneous:*
*
Specify:*
Specify:*
Notes
Select Exam/Region(s) of Interest
- This list covers the most common exams, but it is not exhaustive. An “Other” option is included for additional selections.
X
Select BMD Exam of Interest:*
Specify:
Patient risk factor screening questionnaire will be provided by the imaging facility before or on the day of the exam
Notes
Select Exam/Region(s) of Interest:
- The exam performed is determined by the receiving site based on the "Reason for Exam" and "Region(s) of Interest" selected.
- This list serves two main purposes:
- To assist with triage and routing on the receiver’s end.
- To provide indication-specific clinical guidance and questions to aid in triage (when applicable).
- This list covers the most common Regions of Interest, but it is not exhaustive. An “Other” option is included for additional selections.
- Most Regions of Interest can be selected as a general area (e.g., Head and Thorax). Some require a more specific selection (e.g., Cervical Spine within the Spine category). This is indicated by the required field setting (*) under the Spine category.
X
?
Baseline:
First BMD exam in Ontario
Low Risk:
Patients with prior BMD testing are limited to a second test 3 years later and every 5 years subsequently.
High Risk:
Ordering healthcare provider must provide clinical information documenting reason for high risk status:
- at risk for accelerated bone loss (in the absence of other risk factors, patient age is deemed not to place a patient at high risk for accelerated bone loss);
- with osteopenia or osteoporosis on any previous BMD testing;
- with bone loss in excess of 1% per year as demonstrated by previous BMD testing.
High risk BMD must be >1 year after baseline or >1 year after last high risk exam
X
Specify body area(s) of interest (Optional):
Patient Safety Screening
Renal Assessment Questions: *
Recent (within 3-6 months) estimated Glomerular Filtration Rate (eGFR):
Note: if eGFR is not available at the time of referral, please ensure it is available prior to exam date.
eGFR result:
eGFR date:
If the patient is on metformin, please hold metformin at the time of, or prior to, iodinated contrast administration, and Metformin should not be restarted for at least 48 hours and only then if kidney function remains stable.
Patient on hemodialysis should ideally be scheduled within 2-3 hours after gadolinium contrast administration.
If known, indicate days hemodialysis is scheduled:
Guidance on Contrast Associated Acute Kidney Injury
?
Instruction
For non-emergent presentation of stable outpatients, inpatients, and emergency patients when eGFR is available:
a. If eGFR >30 mL/min/1.73 m2 and no signs and symptoms of acute kidney injury (AKI), then proceed with an indicated contrast imaging study. If eGFR ≤30 mL/min/1.73 m2, or suspected AKI we recommend an individual patient decision involving the caring team, or patient/patient decision-maker to explain and balance the risks of CA-AKI against the risks and uncertainties of delayed or suboptimal imaging.
b. Imaging with ICM can be performed in patients on peritoneal or hemodialysis regardless of residual urine output and no change in dialysis schedule is required.
Macdonald DB, Hurrell C, Costa AF, et al. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. Can Assoc Radiol J. 2022;73(3):499-514. doi:10.1177/08465371221083970
X
?
Instruction
Screening for renal function is only applicable for facilities using Group I Gadolinium-Based Contrast Agents
X
Does the patient have a known hypersensitivity to contrast agents:*
Type of reaction:
?
Instruction
For mild to moderate hypersensitivity reactions, the referring provider can provide the following for the patient to bring to their appointment:
- Oral second-generation antihistamine at least 1 hour before exam (optional)
- Steroid premedication is not recommended
Second/third generation antihistamines include Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, and Rupatadine.
X
Sources:
- Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM et al. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Jan 11. Available from: https://doi.org/10.1177/08465371241311253
- Wang C, Ramsey A, Lang D, Copaescu AM, Krishnan P, Kuruvilla M, et al. Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement from the American College of Radiology and the American Academy of Allergy, Asthma & Immunology. Radiology. 2025 May 1;315(2). Available from: https://doi.org/10.1148/radiol.240100
Last Menstrual Period:
Estimated Date of Delivery:
Please notify the Substitute Decision Maker (SDM) or Power of Attorney (POA) to attend the scheduled appointment with the patient. They may be required to provide pertinent medical history or assist in obtaining such information from appropriate parties.
Requires Sedation:
For patients with claustrophobia requiring oral sedation, the referring physician or nurse practitioner is responsible for prescribing the medications. Patients taking oral sedation must not drive and should arrange alternative transportation.
Rationale:
Patient Safety Screening
Last Menstrual Period:
Estimated Date of Delivery:
Patient Weight and Height
The patient's weight and height auto-populate in metric units from EMRs, if available. Please review and edit as appropriate.
* Mandatory for selected exam(s)
Weight (kgs):
Weight (kgs):*
Height (cm):
Height (cm):*
Weight (lbs):
Weight (lbs):*
Height (ft):
Height (ft):*
Height (in):
Height (in):*
Notes
Patient Height & Weight
- Patient information fields will automatically populate when the referral is initiated from an integrated Electronic Medical Record (EMR).
X
Date of Weight/Height if under 18 years of age:
Patient Safety Screening
Last Menstrual Period:
Estimated Date of Delivery:
Previous Relevant BMD
Date of most recent BMD:
+ Add Attachments
This button is just for demonstration
Number of prior BMD(S):
Location of most recent BMD:
Routing and Scheduling
Specify imaging facility:*
Location:*
Specific appointment date or time interval based on the following clinical reason:
Specify Rationale: *
Timeframe:*
?
Instruction
A Specified Date Procedure (SDP) request is for when an examination is to be completed after a medically specified time interval.
Examples of specified date procedure include:
- Timed Follow-up: Follow up after 6 months
- Procedural: Pre or post surgery
- Navigation: Before specialist appointment
X
Other routing and scheduling considerations
Payer Type:
Specify:
?
Instruction
OHIP: Ontario Health Insurance Plan
WSIB: Workplace Safety and Insurance Board
DND: Department of National Defence
RAMQ: Régie de l'assurance maladie du Québec
IFH: Interim Federal Health Program
X
?
Instruction
Provide rationale for special considerations. Please note that we will make every effort to accommodate preferences based on medical needs, social equity, and convenience.
e.g., Exam bundling, Northern Health Travel Grant
X
Notes
Routing and Scheduling
- This form illustrates the regional central intake process in its early stage (e.g., without central waitlist management technology) and the referring physician is required to state a destination facility for triaging.
- Routing selections on the form will be updated based on the routing capabilities and criteria of the regional intake hubs.
X
Supporting Documentation
Previous Relevant Imaging (if applicable)
+ Add Attachments
This button is just for demonstration
Referrer's Information
Site Name:
Address:
City:
Province:
Postal Code:
Phone:
Fax:
Billing #:
Professional ID:
Signed:
Role:
Thank you for taking time to review this form.
Please provide your feedback in the form on the right-hand side
Ontario Health & Amplify Care
Notes
Overview
- This form is designed for outpatient referrals for CT, MRI, X-Ray, Ultrasound, and Bone Mineral Density (BMD).
- The following sections of the referral form are the same for all imaging modalities: Patient Information, Additional Patient Information, and Referrer's Information.
- The following sections vary depending on the imaging modality: Exam/Region of Interest Selection, Patient Safety Questions, Height and Weight, and Routing and Scheduling Request.
- Mandatory fields are marked with an asterisk (*).
- For optional questions, the referrer is expected to use their judgment and include relevant information on a case-by-case basis.
- Certain questions will be hidden unless specific conditions are met.
- For example, the question regarding diabetes for CT request is only applicable if the estimated glomerular filtration rate is 30 or lower.
- Additional guidance and information are available by clicking
X
?
Notes
Patient Information
- Patient information fields will automatically populate when the referral is initiated from an integrated Electronic Medical Record (EMR).
- This section is the same across specialty forms to provide consistent look-and-feel
X
Notes
Additional Patient Information
- This section is optional for refers to complete
- Referring providers should use their judgment to determine if any of these fields should be completed. Some fields will autocomplete if launched from an integrated EMR or HIS.
- This section is the same across all specialty forms to provide consistent look-and-feel.
X
Notes
Referrer’s Information
- This section is the same across specialty forms to provide consistent look-and-feel
- Referrer information fields expected are saved in the referrer’s Referral Management System and populate automatically on the form
X
Please note that screening programs such the Ontario Breast Screening Program (OBSP) and Ontario Lung Screening Program (OLSP) have dedicated provincial intake forms and eligibility criteria. Please check program website for referral forms.