Referrals and Requisitions

This section is for Health Care Professionals to utilize only.

This page provides access to referral / requisition templates utilized at OSMH.  We will also accept referral / requisitions not on the hospital template if they provide all information required to identify the patient, the referring clinician, the procedure requested and pertinent details.  Any incomplete or illegible referrals / requisitions will be sent back to the referring provider requesting further information before a procedure can be scheduled.

Diagnostic Imaging now accepts eReferrals! Please check the OCEAN Health Map for more information.

If you are a primary care provider and want to sign up for OCEAN eReferral, complete the online quick form or email

Referral / Requisition Forms:

Acute Cardiac Evaluation Services Form

Anesthesia Procedural Clinic Referral Form

Anesthetic Consult Request Referral Form

Asthma Referral Form

Cardiac Diagnostics Referral Form

Cardiac Rehabilitation Referral Form

Cardioversion Request Form

CHAT Referral Form

Couchiching Ontario Health Team Care Clinic Referral Form

CT Exam Form

EEG Requisition Form

General Genetics Referral Form

Cancer Genetics Referral Form

Interventional Procedure Form

Mammography Bone Density Exam Form

Mental Health Outpatient Services Referral Form

MRI Exam Form

Nuclear Medicine Exam Form

MSK-CI-Referral Form

Outpatient Rehabilitation Services Referral Form

Paediatric Eating Disorder Program Referral Form

Pregnancy Related Dilation and Curettage Referral Form and Patient Information

Remdesivir Referral Form

Respiratory Testing Referral Form

Surgery Booking Request Form - OSMH Surgeon Use Only

Telederm Referral Form

Ultrasound Exam Form

Videoflouroscopy Referral Form

XRAY Exam Form

If you should require a referral form not listed above, please contact the phone number below.

General questions about patient scheduling can be directed to 705.325.2201 option 3.

Should you have questions about Central Scheduling and/or Scheduling practices at OSMH, please contact central scheduling or registration at 705-325-2201 Ext: 8001