Health Care Information Sheets & Referral Forms

Preparing for Your Procedure

At PSFDH, we want to ensure you have the information you need to ensure the best possible outcomes for your care. Below are Health Care Information Sheets and Referral Forms on a variety of services and procedures offered at the hospital.

 

If you have additional questions, please speak with your health care provider.

 

Patient and Family Information Guide 2025

Diagnostic Imaging

• Pocket Health - Download details on how you can access your imaging records
• Xray Requisition (June 2019)
• Cardiac Testing Requisition
• CT Scan Requisition (April 2025)
• MRI Requisition
• Pulmonary Requisition
• Ultrasound Requisition

• Patient Information Sheet - MRI Scan
• Patient Information Sheet – Ultrasound Preparation Instructions
• Patient Information – Abdomen and Pelvis Ultrasound
• Patient Information Sheet – Abdomen Ultrasound
• Patient Information Sheet – Barium Enema
• Patient – Information – Bone Mineral Density
• Patient Info Sheet – Echocardiogram
• Patient Information Sheet – CT Scan
• Patient Information Sheet – Carotid Doppler Ultrasound
• Patient Information Sheet – Mammogram
• Patient Information Sheet - Medical Day Unit Blood Product Order Set
• Patient Information Sheet -Obstetrical Ultrasound
• Patient Information Sheet – X-Rays, Pregnancy and you
• Patient Information – Pelvis Ultrasound
• Patient Information Sheet – Small Bowel – Follow Through
• Patient Information – Upper GI Series or Barium Swallow
• Patient Information Sheet – Radiology IV Contrast – Discharge Instruction

Day Hospital (Out-Patient/Rehab)  

• Referral Form

Rehabilitation Services (In-Patient)

• Admission Criteria
• Referral Form

 

Lanark County Sexual Assault & Domestic Violence Program

• Referral Form 

Medical Day Clinic (GWM/Perth Site)

• Process for Accessing Medical Day Care Unit
• Medical Day Unit Referral Form
• Laboratory Requisition

      Blood Transfusion Forms

• Consent to Receive Blood Component
  
• Medical Day Unit Blood Product Order Set
• Pamphlet - About Blood Transfusions
• Pamphlet - Going Home After A Blood Transfusion

       Iron

• Iron Infusion Order Set
• Venofer Patient Information
• Monoferric Patient Information

      IVIG

• IVIG Patient Information
• MOHLTC IG Request Form - For Neurology Use Only 
• MOHLTC IVIG Request Form - Non-Neurology Patients

• Therapeutic Phlebotomy Order Set 

Orthopedics (Central Intake Assessment)

•  Regional Arthritis Hip & Knee Replacement Program - Referral Form