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Trillium Health Partners

Requisitions & Forms

​The following requisitions and referral forms are available for health care providers.

NOTE:
These forms are for one-time print and use only. Do not photocopy. Copies will become outdated - referring patients via an outdated form will result in processing delays.
Always use a recently downloaded and printed form.
Requisition forms must be signed by a referring physician.


Referral to Clinical Genetics

Clinical Genetics Referral Form 3990 D HR Familial Cancer Genetics Program Referral Form 3991 D HR Cardiogenetics Program Referral Form 3992 D HR

Amniocentesis

Amniocentesis procedure referral form 1002 D HR

Requisitions

Familial Hypercholesterolemia Testing Requisition 3998 D Molecular Genetics Hereditary Cancer Testing Requisition 3979 D Prenatal Screening Requisition – Trillium Health Partners external
(for Down Syndrome, Trisomy 18 and ONTD) Oncology Genetic Testing ​Requisition 3997 D Constitutional Cytogenetics Testing Requisition 3803 D Microarray Genetics Testing Requisition 3804 D Molecular Genetics Diagnostic Testing Requisition.pdf 3805 D

Prenatal Genetics

Laboratory Licenses

For Laboratory Licenses and Accreditation Certificates, see this page »


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