Referral Form

• Cancer Care Ontario-William Osler Health System Thoracic Oncology Referral Form
• Referral for Lung Cancer Screening at William Osler Health System
• Referral Form for any referral to the Thoracic Surgery Clinic at William Osler Health System

E-Referral

Patient

First Name

Last Name

Date of Birth

Health Card Number

Intake

Referring Doctor

Practitioner Number

Select reason for referralPossible Lung MalignancyPossible Esophageal MalignanacyBenign Esophageal DiseaseMediastinal abnormalitiesHypherhidrosisChest wall deformities

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