Referral Forms

View or download the following referral forms, instructions, or guidelines:

Provincial

• AlbertaQuits Helpline Referral Form
  Used for the following program or service: AlbertaQuits Helpline
• Driver Education & Training Service Referral Form
  Used for the following program or service: Driver Education & Training Service
• Alberta Hip & Knee Replacement Referral Form 
  Used for the following program or service: Hip & Knee Replacement
• Tuberculosis Referral
  Used for the following program or service: Tuberculosis Referral

Zone 1 - South

Zone 2 - Calgary

• Central Access and Triage Referral Form and Information
  Used for the following program or services: Cardiac Care, Clinical Neurosciences, Palliative, Women's Health, Medical & Surgical Services, Cancer Care
• Community Accessible Rehabilitation Referral
  Used for  the following program or service: Community Accessible Rehabilitation Referral
• Dental Clinic Referral Form (FMC) 
  Used for the following program or service: Foothills Medical Centre Dental Clinic
• Integrated Home Care Physican Referral
  Used for the following program or services: Integrated Home Care
• Neuropsychological Assessment Referral
  Used for the following program or service: Foothills Medical Centre Neuropsychological Assessment
• Outpatient Dysphagia Clinic Referral Form
  Used for the following program or service: Outpatient Dysphagia Clinic
• Referral to/from Postpartum Community Services Including Jaundice Screening
  Used for the following program or service: Postpartum Community Services Including Jaundice Screening

Zone 3 - Central

• Chronic Disease Management Program Referral
  This referral is used for Diabetes Education and Care, Heart Health, Self-Management and Healthy Lifestyle Education.

Zone 4 - Edmonton

• Adult Chronic Pain Specialist Referral
  Used for the following program or services: LifeMark Chronic Pain Program; Multidisciplinary Pain Centre (UAH); and Misericordia Pain Clinic
• Adult Diabetes Centre Referral Form
  Used for the following program or service: Regional Diabetes Program
• Cancer Genetics Clinic – Referral Protocols and Criteria
  Used for the following program or service: Medical Genetic Services
• Children's Mental Health Regional Intake Form / Parent/Guardian Information Sheet
  Used for the following program or service: Children's Mental Health - Intake Line 
• Community Audiology Service - Edmonton Zone Referral Form   
• Comprehensive Breast Care Program (CBCP) Referral Form
  Used for the following program or service: Comprehensive Breast Care Program
• Feeding and Swallowing Referral Form (Outpatient Services)
• Geriatric Division Central Intake Referral Form
  Used for the following program or services: Assessment and Rehabilitation, Older Adults - Inpatient (Units 3D & 4C); Assessment and Rehabilitation, Older Adults - Inpatient (UNIT 4D); and START Medical Day Hospital
• Maternal Prenatal Screen Requisition Form 
• Medical Genetic Services Referral Form 
  Used for the following program or service: Medical Genetic Services
• Medical Specialists & Medical Services Central Access & Triage Form
  Used for the following program or service: Lymphedema Management Program
• Northern Alberta Cardiac Rehabilitation Program Referral Form
  Used for the following program or service: Cardiac Rehabilitation Program
• Pediatric Outpatient Physical and Occupational Therapy Services Referral Form
  Used to make Pediatric Outpatient referrals to the Stollery Children’s Hospital 
• Seniors Mental Health Programs – Edmonton Zone Integrated Referral
  Used for the following program or service: 
• Seating Service Referral Form
  Used for the following program or service: Seating Service
• Spasticity Program for Adults Clinical Referral Form
  Used for the following program or service: Spasticity Program for Adults
• Specialized Geriatrics Outpatient Referral Form
  Used for the following program or service: Specialized Geriatrics
• Stroke Prevention Clinic Referral Form
  Used for the following program or service: Stroke Clinic
• Voice/Resonance Clinic Referral Form
  Used for the following program or service: Voice Clinic; Resonance Clinic
• Weight Wise Adult Referral Form
  Used for the following program or service: Weight Wise Adult Weight Management Clinic
• Weight Wise Pediatric Referral Form
  Used for the following program or service: Pediatric Centre for Weight and Health (17 and under)
• Weight Wise Prior Bariatric Surgery Referral Form
  Used for the following program or service: Weight Wise Adult Weight Management Clinic

Zone 5 - North

• Living Well Program Referral
  Used for the following program: Living Well Program (North Zone)