Provis Oncology Clinic

Referring a Patient for Treatment

To refer a patient to the Provis Infusion Clinic download and complete the patient Referral Form and return to us by fax.

Download & Print the Patient Referral Form

Click the button to download, open and print the Provis Infusion Clinic patient referral form in adobe (.pdf) format. When you have completed the referral form please return it via fax: (416) 532-3635

Each referral is reviewed by a Provis physician. The application is then processed and the patient contacted to discuss insurance coverage and cost of treatment. We will notify you as to the date of start of therapy and request completion of a prescription for therapy (Medication Order Form, see below).

Each cycle of therapy requires the completion of a new Medication Order as it is expected that patients will be reviewed regularly by their treating oncologist prior to each cycle of therapy.

Important: All medication orders are reviewed by a pharmacist and countersigned at the Provis Infusion Clinic by a staff physician prior to starting therapy. In all supporting documents forwarded to the insurer it is important to indicate that the treatment will be delivered in a private clinic outside of a public hospital.

Provis Formulary
No drug will be given at the Provis Infusion Clinic Inc. if it is available and funded in the public system in Ontario for the particular indication and the patient fulfills guideline criteria for public funding.

Provis Infusion Clinic will keep a limited formulary at any given time. Some medications may not be available because of medical concerns regarding their administration in the non-hospital setting. We reserve the right to restrict the drugs administered in the Provis Infusion Clinic.

Current Drugs Available:
To download and print specific medication order form, click on the link next to the medication.

• Abraxane (nab-paclitaxel) [order form & information]

• Alimta(pemetrexed) [order form]

               (cisplatin will require administration at alternate facility)

• Avastin(bevacizumab) [order form & information]

• Caelyx(Pegylated Liposomal Doxorubicin) [order form & information]

• Eloxatin(OXALIPLATIN injection)  [order form & information]

• Erbitux(Cetuximab) [order form & information]

• Gemzar (gemcitabine)* [order form]

• Herceptin(Trastuzumab)* [order form & information]

• Rituxan(Rituximab)* [order form & information]

• Torisel(temsirolimus injection)  [order form & information]

• Vectibix(Panitumumab) [order form & information]

• Zometa(zoledronic acid)* [order form]

                    * for indications outside of guideline funding.

Physician - Frequently Asked Questions

Q: Can drugs other than those listed on the formulary be given at the Provis Infusion Clinic?
A: At this time only single agent treatments will be administered at the Provis Infusion Clinic. There may be circumstances where patients will require an additional intravenous medication from their treating oncologist. In such cases the treatments will be coordinated and scheduled appropriately.

Q: Who is the "most responsible physician" (MRP)?
A: Provis Infusion Clinic Inc. will be responsible for all aspects of patient care during their time at our clinic. Acute treatment-related issues will be handled by the Provis medical staff with referral to local health facilities as deemed necessary. If complications from treatment arise after leaving the Provis Infusion Clinic patients will be instructed to go to the local emergency room or contact their oncologist depending on the urgency of the problem.

Q: What kind of medical record will document the treatment given?
A: A record of infusion is faxed to the referring physician after each treatment at Provis Infusion Clinic. The referring physician also receives a final treatment summary by fax upon completion of the treatment schedule or in case of termination of treatment.

Q: What happens if an "unfunded" drug becomes funded during the time that the patient is attending Provis Infusion Clinic?
A: In keeping with our formulary policy the patient will be informed of the availability of the drug in the public system and will be asked to consult their treating oncologist about continuing a therapy that has been started at Provis Infusion Clinic.

Q: What kind of medical supervision is provided at Provis Infusion Clinic?
A: A physician is present at all times during patient treatment sessions. Registered oncology nurses, specialized in chemotherapy infusion, administer medications. For Radioimmunotherapy, an experienced nuclear medicine technologist and oncology nurse will be present. Our staff has an average of seven years in-hospital oncology nursing experience. Emergency procedures and 911 protocol are established.

Q: What happens if Provis Infusion Clinic declines to treat the patient for medical reasons?
A: If treatment is declined because of poor patient condition or abnormal laboratory results (preventing the administration of an agent), the attending oncologist who referred the patient will be contacted as to the reason for withholding treatment. A written record will accompany the patient on leaving the clinic to be taken to his/her attending oncologist. Provis Infusion Clinic Inc. reserves the right not to administer a treatment if felt medically inappropriate.

Q: Does this violate the Canada Health Act?
A: No. Outside of a public hospital patients may purchase medications and have them infused by a service provider.

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