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Eastern Health Forms and Resources

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Allied Health Professional Practice: for Health Professionals

Cancer Care: for Health Care Professionals

Drug Shortage Framework

Eating Disorders - Community Capacity Building (CCB)

Janeway Lifestyle Program: for Health Professionals

Laboratory Medicine: for Health Professionals

Palliative Care for Health Professionals

Paramedicine and Medical Transport: for Health Professionals

Perinatal Program: for Health Professionals

Research Involving Eastern Health

Student Services

Eastern Health Forms and Resources

Allied Health Professionals
Ch-1311 Dental Assessment Saliva Management Clinic Form (PDF, November 2014)

Ambulatory Care
Ch-1009 Endoscopy Request for Consultation - Adults (PDF)
Ch-1150 Wound Care Referral Form (Acute Care) (PDF) Ch-1452 Lipid Clinic Referral Form (PDF)

Cancer Care
Ch-1116 Patient Referral Form [Editable PDF, December 2014]

Screening

Ch-1069 Abnormal Pap Cytology/Colposcopy Referral From [Editable PDF, April 2013]
NL Colon Cancer Screening, Physician Referral Form for Fecal Immunochemical Test Kit (FIT) (PDF)

Cancer Care for Health Care Professionals

Cardiac Care

Ch-0394 Cardiac Cath Lab Booking Form (PDF)
Ch-1119 Cardiac Cath Lab Electrophysiology Booking Form (PDF)
Ch-0736 Echocardiography Requsition Form (PDF)

Children and Women's Health
Ch-0351 Janeway Children's Hospital Ophthalmology Referral Form (PDF)
Ch-0879 Janeway Lifestyle Program Referral form (ages 2 to 14) (PDF)
Ch-1311 Dental Assessment Saliva Management Clinic Form (PDF, November 2014)

Other Resources:

Diagnostic Imaging
Ch-0078 Request for Mammography Exam and Consultation (PDF, Oct. 2014)
Ch-0777 Request for Magnetic Resonance Imaging (MRI) (PDF, Nov. 2017)
Ch-0776 Diagnostic Imaging Request for Examination Consultation (PDF, Jan. 2015)
Ch-0017 Consent for Release/Request of Personal Health Information (PDF)
Ch-1556 Request for Positron Emission Tomography (PET) Imaging (PDF)

Other Resources:

Laboratory Medicine

Ch-0177 Laboratory Requisition Form (Outpatient Specimen Collection) Feb. 2017 (PDF)
Ch-0618 Pathology Specimen Requisition Form (PDF)

Ch-1652 Postnatal Microarray Requisition Form (PDF)
Ch-0764 Constitutional Cytogenetics Requisition Form (PDF, 2017)
Ch-0771 Flow Cytometry Requisition Leukemia/Lymphoma Form (PDF)
Ch-1183 Molecular Genetics Lab Requisition Form (PDF)
Ch-1372 Maternal Serum Screen Requistion Form (PDF)
Ch-1193 Cytogenetics Requisition for Amniocentesis Form (PDF)
Ch-1254 Laboratory Test Special - Authorization Form (PDF, May 2017)

Ch-022 Microbiology Referral form (2016) PDF

Ch-1357 Cytology Non-Gyn Requisition (PDF, October 2017)

Ch-1413-Placental Pathology Requisition (PDF, May, 2017)

Other Resources:

Medicine Services

Ch-1331 Application for Funding - Adult Insulin Pump Program Newfoundland and Labrador (PDF, 2014)
Pamphlet, Learn more about the Adult Insulin Pump Program (PDF, 2014)

Vascular
Ch-1379 Vascular Lab Request for Examination (PDF)

Urology Services

Ch-1576 Urology Central Intake Patient Referral (PDF)

Rheumatology

Ch-0786 Central Triage and Referral Form Rheumatology Form (PDF)

Mental Health and Addictions
Ch-0016 Mental Health and Addictions Services Referral Form (PDF, 2013)
Ch-1312 Tuckamore Centre (Youth Treatment Centre) Referral Form (PDF, Aug. 2014)
Tuckamore Centre (Youth Treatment Centre) Medical Assessment for Referral Package (PDF, Aug. 2014) Ch-1390 The Grace Centre Referral Form (Ch-1390 Adult Addictions Inpatient Treatment) (PDF, Mar. 2016)
Ch-1391 The Grace Centre Medical Assessment Form (Ch-1391 Adult Addictions Inpatient Treatment) (PDF, Mar. 2016)

Other Resources:

Palliative Care

Ch-1151 Referral Form Palliative Services Symptom Management (PDF, May 2017)

Ch-1300 Grief and Bereavement Referral Form (PDF, May 2017)

Other Resources:

Palliative care for health providers

Surgery
Ch-0987 Schedule for Elective Surgery (PDF)
Ch-0985 Checklist for Completion of O.R Booking Package (PDF)

Bariatric Surgery
Ch-1577 Bariatric Surgery Booking Form (PDF, May 2017)

Orthopedic Services
Ch-0983 Orthopedic Central Intake Patient Referral Form (PDF)
Ch-1241 Request for Spine Consultation Orthopedic Central Intake (PDF)

Other Resources:

Thoracic Services
Ch-1323 Request for Thoracic Surgical Consultation Thoracic Central Intake (PDF)

Pastoral Care and Ethics
Ch-1225 Request for an Ethics Consultation Form 2013 (PDF)

Other Resources:

Accountability for Reasonableness (A4R) (PDF): An ethics and values based framework for the planning, priority setting, and allocation of resources of programs and departments.

Printing Services
Ch-0787 Printing Requisition Form (PDF)

Rehabilitation and Continuing Care
Center for Pain and Disability Management Form (PDF)
Ch-1383 Rehabilitation Day Services Referral Form (PDF)

Pulmonary Rehabilitation
Ch-1397 Pulmonary Rehabilitation Referral Form (PDF, January 2016)

Updated Feb 2, 2018

For Health Professionals