Eastern Health - Eastern Health Forms and Resources

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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

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
Dental Assessment Saliva Management Clinic Form (PDF, November 2014)

Ambulatory Care
Endoscopy Request for Consultation (PDF)
Wound Care Referral Form (PDF)

ch-1452 Lipid Clinic Referral Form (PDF)

Cancer Care
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

Cardiac Cath Lab Booking Form (PDF)
Cardiac Cath Lab Electrophysiology Booking Form (PDF)
Echocardiography Requsition Form (PDF)

Children and Women's Health
Janeway Children's Hospital Ophthalmology Referral Form (PDF)
Janeway Lifestyle Program Referral form (aged 2- Pre K) (PDF)
Janeway Lifestyle Program Referral form (aged 5-14) (PDF)

Janeway Dentistry: Newborns with Cleft Lip and Palate, a resource guide (ENG, PDF)

Janeway Dentistry: Nourrissons présentant une fente labio-palatine, ressource (FRE, PDF)

Dental Assessment Saliva Management Clinic Form (PDF, November 2014)

Diagnostic Imaging
Ch-0078 Request for Mammography Exam and Consultation (PDF, Oct. 2014)
Ch0777 Request for Magnetic Resonance Imaging (MRI)

MRI Safety - Guidelines for Healthcare Providers (PDF, 2015)

Physician Quick Reference Guide (PDF)

Ch 0776 Diagnostic Imaging Request for Examination Consultation (PDF, Jan. 2015)
Consent for Release/Request of Personal Health Information (PDF)
Frequently Asked Questions

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)
Flow Cytometry Requisition Leukemia/Lymphoma Form (PDF)
Molecular Genetics Lab Requisition Form (PDF)
Maternal Serum Screen Requistion Form (PDF)
Cytogenetics Requisition for Amniocentesis Form (PDF)
Laboratory Test Special - Authorization Form (PDF, May 2017)

Ch-022 Microbiology Referral form (2016) PDF

St. John's and area -

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

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)

Mental Health and Addictions
Mental Health and Addictions Services Referral Form (PDF, 2013)
Listing of Mental Health and Addiction Services and contact information (PDF, June 2017)
Mental Health Care and Treatment Act
Mental Health Care and Treatment Act - Associated Forms
Adult Central Intake (MHA) - for St. John's region only
Tuckamore Centre (Youth Treatment Centre) Referral Form (PDF, Aug. 2014)

Tuckamore Centre (Youth Treatment Centre,) Medical Assessment for Referral Package (PDF, Aug. 2014)

The Grace Centre Referral Form (Ch-1390 Adult Addictions Inpatient Treatment) (PDF, Mar. 2016)

The Grace Centre Medical Assessment Form (Ch-1391 Adult Addictions Inpatient Treatment) (PDF, Mar. 2016)

Mental Health and Addictions Resources:

Palliative Care

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

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

Surgical Services

Bariatric Surgery
Bariatric Surgery Booking Form (PDF, May 2017)

Orthopedic Services

Orthopedic Central Intake Patient Referral Form (PDF)
Orthopedic Central Intake Update for GPs
Orthopedic Central Intake Patient Information Sheet (PDF)
Request for Spine Consultation Orthopedic Central Intake (PDF)

Thoracic Services

Request for Thoracic Surgical Consultation Thoracic Central Intake (PDF)

Vascular

Vascular Lab Request for Examination (PDF)

Urology Services

Ch-1576 Urology Central Intake Patient Referral (PDF)

Pastoral Care and Ethics
Request for an Ethics Consultation Form 2013 (PDF)
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
Printing Requisition Form (PDF)

Rehabilitation
Center for Pain and Disability Management Form (PDF)

Ch-1383 Rehabilitation Day Services Referral Form (PDF)

Pulmonary Rehabilitation
C

h-1397 Pulmonary Rehabilitation Referral

Form (PDF, January 2016)

Rheumatology
Central Triage and Referral Form Rheumatology Form (PDF)

Surgery
Schedule for Elective Surgery (PDF)
Checklist for Completion of O.R Booking Package (PDF)

Updated Jul 27, 2017

For Health Professionals