CUSTOM FORMS
for TELUS (PS Suite) EMR
Diagnostics:
- 2014 Lab Req with Buttons – (already included FREE in this toolbar)
- Ontario Breast Screening Program (OBSP) – HIGH RISK Requisition
- North York General eFTS (2020)
- LifeLabs Flow Cytometry Requisition (Doc # 20167 | Ver: 6.0 | 09-Nov-2017)
LHIN/CCAC:
- SELHIN Hip and Knee Replacement Referral Form
- SELHIN Low Back Pain Rapid Access Clinic
- CADD Pump Prescription Order (SELHIN) (2018)
Referrals:
- Bounceback Ontario Mental Health Counselling
- CPM Centres for Pain Mangement Central Intake Form
- OTN Telemedicine Clinical Referral Form (March 2013)
- Arthritis Society Rehab and Education Referral Form (March 2007)
- Neurology Centre of Toronto, Virtual Rapid Access Clinic (2020-05-02)
QHC:
- QHC Barium Swallow Intake Form for Shirley Williams
- QHC Abnormal FIT Referral
- QHC BMD (2019)
- QHC Breast Imaging (2019)
- QHC CardioPulmonary (2020)
- QHC CT Colonography (2019)
- QHC CT (2019)
- QHC Interventional Radiology (2019)
- QHC MRI Breast (2016)
- QHC MRI (2019)
- QHC Nuclear Cardiology (2016)
- QHC Ultrasound (2019)
- QHC Xray (2019)
- QHC Medical Day Clinic – Iron Infusion (v2019)
- QHC Medical Day Clinic – Consent Form
- QHC Medical Day Clinic – IVIG
- QHC Medical Day Clinic – Phlebotomy
- QHC Medical Day Clinic – RBC Transfusion
- QHC Medical Day Clinic – Referral Cover
- QHC LinkAGE Clinic Referral
- QHC Addictions and Mental Health Services Access Form (310-OPEN)
- QHC Cancer Centre of Southeastern Ontario Referral Form (Dec 2019 V9.3)
- Loyalist College Immunization Form
LHIN/CCAC:
- CCAC IV Therapy (Sept 2011)
- CCAC Request for Services (Oct 27/14)
- CCAC Referral (2009)
Independent Diagnostics:
- Kente and Belleville Xray and Ultrasound (2018)
- Bluewater Imaging (2020)
- STL Diagnostic Imaging (in Madoc) Requisition
- Cardiology Services Group Requisition
- Quinte Regional Sleep Clinic
Local Referrals:
- Quinte Paediatrics Referral (2020) (FREE – download here)
- Medigas COVID-19 Oxygen Requisition v2020 (FREE)
- Medigas Home Oxygen Assessment (2020) (FREE)
- Medigas Home Sleep Screening (FREE)
- Gateway High Risk Foot Care (2017)
- Breg Braces (via Joe Doran) Referral and Prescription (FREE)
- Heart of Hastings Hospice Referral (2019)
- Heart of Hastings Hospice Madoc Admission Orders
- Public Health Animal Bite Scratch Reporting Form (Hastings Prince Edward) (2016)
- Belleville Quinte Ophthalmology Referral Form v2019 (already on website)
- Highland Shores Children’s Aid Health Report (Oct 3, 2020)
- COVID-19 Assessment Centre – Hastings Prince Edward Public Health (April 2020)
CMH:
- CMH Sleep Study
- CMH Ambulatory Blood Pressure
- CMH CT (2019)
- CMH CT Consent
- CMH Echo (2019)
- CMH Diagnostic Imaging (2019)
PRHC:
- PRHC Breast Imaging
- PRHC CT (2005)
- PRHC Diagnostic Imaging
- PRHC MRI (2012)
- PRCH PFTs
Independent Diagnostics:
- Peterborough Pine Ridge and Kawartha Imaging (2011)
- Peterborough Vascular Lab (PVL)
Local Referrals:
- Dr. Gooderham Skin Dermatology
- HDH Triage Intake Form (Request for Non-Urgent Clinic Appointment)
- KRCC Lung Diagnostic Assessment Program (Aug 2017)
- KGH Obstetrical Ultrasound
- Providence Care Behavioural Support Services Referral / Seniors Mental Health (500199 | 2020/09)
- COPD Action Plan (by Canadian Respiratory Guidelines)
- HABC Dementia Vitals Questionnaire
- Diabetes 60-Second Diabetic Foot Screen (Canadian Association of Wound Care)
- MOCA (Montreal Cognitive Assessment)
- Sunlife Financial Attending Physicians Statement – Short-Term Disability Claim (020-3485-11-10)
- Canada Life Attending Physicians Statement – Disability Benefits (306 CAN-12/13)
- Green Shield Canada Prescription Drug Special Authorization Request Form (General)
- Green Shield Canada Erectile Dysfunction Special Authorization Request Form (Rev 2012-01)
- Medavie Blue Cross – Attending Physicians Statement (General) (FORM-401E)
- Combined Insurance – Attending Physicians Statement (294590)(09/2016)
- CUMIS Insurance – Proof of Death (EP-012 CU 0408)
- Manulife Attending Physicians Statement – Short Term Disability (GL4221E (05/2019))
- Manulife Drug Prior Authorization – Ozempic (Semaglutide) (GL5197E – MLI (05/2023)) – Generic. (FREE – CLICK HERE)
- Manulife Drug Prior Authorization – Ozempic (Semaglutide) (GL5197E – MLI (05/2023)) – for Obesity and Weight Loss, pre-populated with supporting evidence. (FREE – CLICK HERE)
- GSK Trelegy Ellipta Patient Support Program Referral
- Ozempic Novo Nordisk Reimbursement Program
Typical One-Time Fee
$49/form/physician
- (based on minimum 8 physicians)
- No ongoing subscription fees
- Contact us for a Quote
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