Refer a Patient to WWRCP

You can refer a patient to a service or program within the Waterloo Wellington Regional Cancer Program by filling out a referral form.

Please refer to the accordions below for the required forms.

Hospital Programs

Waterloo Wellington Regional Cancer Program

Referral Form	Location	Completed Referral Must Also Include
WRHN Cancer Centre New Patient Referral Form	WRHN Cancer Centre Referral Options: 1) Fax Referral Form	Pathology reports documenting cancer diagnosis
Cambridge Memorial Hospital Outpatient Oncology Program New Patient Referral Form	CMH Outpatient Oncology Program Referral options: Ocean eReferrals Fax Referral Form If using Ocean: Search the Ocean Healthmap for "Cambridge Memorial Hospital Outpatient Oncology Program" Add to your favourites list for quick access Complete and submit your eReferral	A consultation letter highlighting presenting signs, symptoms and findings Signature of referring physician or Nurse Practitioner
Waterloo Wellington Hospitals Breast Imaging Requisition (Screening Referral or *Diagnostic Referral)	Cambridge Memorial Hospital Guelph General Hospital* Waterloo Regional Health Network, Freeport Campus* (Waterloo Wellington Breast Centre) Groves Memorial Community Hospital	Exam Information

Palliative Care

Referral Form	Location	Completed Referral Must Also Include
Palliative Care Inpatient/Hospice Services	Waterloo Regional Health Network Groves Memorial Hospital St. Joseph's Health Centre Guelph Lisaard & Innisfree Hospice Hospice Wellington Hospice Waterloo Region	Isolation issues COVID-19 Status Outstanding medical investigations
Genetic Counselling Referral Form (including family history questionnaire) More information below this chart.	WRHN Cancer Centre	Patient consent for genetics referral Completed Family History Questionnaire
Malignant Pleural Effusion Clinic	WRHN Cancer Centre	n/a
Multidisciplinary Case Conferences	WRHN Cancer Centre	Imaging and pathology information and booking dates Signature

Program Overview – Cancer Genetics Clinic

The Cancer Genetics Clinic offers genetic counselling and risk assessments for people who have had cancer themselves, or who have a family history of cancer.

We help people understand if cancer in their family may be hereditary (passed down through genes), and what they can do to manage their risk of getting cancer in the future.

We also check if someone qualifies for the High Risk Ontario Breast Screening Program (HROBSP).

👉 Please note:
Our clinic only looks at genetic conditions related to cancer. If you need help for a different type of genetic concern (not related to cancer), please visit the Ontario Health Genetic Clinic Directory to find the right clinic: https://www.ontariohealth.ca/clinical/genetics/clinic-directory

Program Information

Location:

Waterloo Regional Health Network (WRHN) Cancer Centre @ Midtown
Hours: Monday – Friday; 8:00 am – 4:00 pm

Contact Information:

Phone: 519-749-4300 ext 2832
Fax: 519-749-2025
Email: [email protected]
Referral Form

For guidance regarding genetics services in Ontario, please contact gcConnect.

gcConnect is an Ontario-wide network of genetic counsellors at regional partner sites supporting non-genetics clinicians in navigating genetic services for their patients.

A direct line for clinicians to connect with a genetic counsellor via email or phone.

Email: [email protected]
Telephone: 1-844-564-4363 (GENE) or 437-317-1057
Monday to Friday, 9 AM to 12 PM and 1 PM to 4 PM

Screening & Assessment Programs

Breast, Cervical, Colorectal, Lung

Disease Site	Referral Form	Location of Service	Completed Referral Must Also Include
Breast	High Risk Ontario Breast Screening Program	Waterloo Regional Health Network - Freeport Campus	Most recent mammogram report (if available) Previous genetic testing or risk assessment results (Required for category A and if available, include for category B)
Cervical	Waterloo Wellington High-Grade Colposcopy Central Referral Program	Regional Colposcopists across Waterloo Wellington	n/a
Colorectal	Waterloo Wellington Coordinated Colonoscopy Assess Program	Regional GI Endoscopists or Colorectal Surgeons	n/a
Lung	Lung Diagnostic Assessment Program	WRHN Cancer Centre	CT chest report Abnormal chest x-ray report

Community Care

Ontario Health atHome

Referral Form	Location	Completed Referral Must Also Include
Ontario Health atHome	Ontario	n/a
Community Palliative Care Ontario Health atHome	Ontario	n/a

For more information contact us:

WRHN Cancer Centre’s New Patient Referrals (NPR) office:

519-749-4370 extension 5720

[email protected]