Eastern Health - Eastern Health Forms and Resources

Eastern Health Forms and Resources

For Our Staff

Physician Portal

Allied Health Professional Practice: for Health 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)

Ch-0415 Outpatient Dietitian Referral Form (PDF)

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]

Ch-0528 Hematology Oncology Dietitian Referral Form (PDF)

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:

Breastfeeding:

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:

Grief and Bereavement

Ch-1300 Grief and Bereavement Referral Form (PDF, Editable, 2019)

Medicine Services

Ch-1331 Application for Funding - Adult Insulin Pump Program Newfoundland and Labrador (PDF, 2014)
(PDF, 2014)

Pamphlet, Learn more about the Adult Insulin Pump Program

Diabetes

ch-0813_Diabetes_Program_Referral_Form Fillable

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)

Neurology
Ch-1918 Neurology Outpatient Referral 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 Mar 4, 2019

For Health Professionals

Site Map

Disclaimer