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Outpatient/Ambulatory

These forms are periodically modified. To make sure you are using the most current version of the form you require, please download it from this webpage.


The form is for all referrals to day hospital programs and/or outpatient rehab services where more than one rehab service is required, except:

  • Acute care referrers in Toronto who use the E-Stroke Rehab Referral system for stroke rehab referrals should continue to use the electronic referral system for outpatient referrals
  • Referrals for patients with an Acquired Brain Injury should use the Toronto ABI Network's Community Profile, which can be downloaded at http://abinetwork.ca/community-form

Outpatient/Ambulatory Rehab Referral Forms

Rehab Population

Printable-Only Form (PDF)
(must be printed, completed on paper, then faxed)

Fillable Online Form (Word)
(may be completed online, then printed and faxed)

All Rehab Populations except Total Joint Replacements and Acquired Brain Injury Outpatient/Ambulatory Rehab Referral Form - PDF

Outpatient/Ambulatory Rehab Referral Form - Word

Outpatient Rehab Referral Form - Elective Knee or Hip Replacement

Outpatient Rehab Referral Form - Elective Knee or Hip Replacement - PDF

TJR Outpatient Programs - PDF

 

 

TJR Outpatient Rehab Follow-Up Form - PDF

 

Outpatient Rehab Referral Form 
- Acquired Brain Injury

ABI Community Profile

 

 

Other

Referral forms for other types of service may be accessed through the links below: