Région de Centre-Est

Centralized Diabetes Intake Referral FormFor Access to Diabetes Education Programs and the Centre for Complex Diabetes Care Phone: 1-888-997-9996 Fax: 1-905-444-2544 Toll Free Fax: 1-844-731-2161

Community Paramedicine Referral Form

Central East – COPD and Heart Failure Telehomecare Referral Form

Formulaire de renvoi à Télésoins à domicile pour les patients atteints d’une maladie pulmonaire obstructive chronique (MPOC) ou d’une insuffisance cardiaque
congestive.

Les patients inscrits au programme de surveillance à distance utilisent une application sur leur téléphone intelligent pour communiquer leurs symptômes à l’infirmière.

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

At Ontario Health atHome, we are committed to leading the advancement of an integrated sustainable health care system that ensures better health, better care and better value. Your feedback is important to us.

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

Centre-Est, Formulaire de renvoi à Télésoins à domicile pour les patients atteints d’une maladie pulmonaire obstructive chronique (MPOC) ou d’une insuffisance cardiaque congestive.

Hip and Knee Referral Form

Hospital Infusion Therapy Referral Form

Hospital Narcotic Infusion Therapy Referral Form

Hospital Request for Assessment Form

Infusion Therapy Referral Form

Central East Medical Assistance in Dying Prescription Order Form

To be eligible to receive Ontario Health atHome MHAN services the student must be:
– A Registered student (up to age 21) (can include home instruction)
– In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
– Aware and have consented to the referral

Narcotic Infusion Therapy Referral Form

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Patient Appeal Form

Central East, PrVEKLURY® Remdesivir Infusion Referral Form. Please ensure form is completed for accuracy.

Request For Assessment Form

Request For Assessment Form – French

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

Symptom Response Kit (SRK) for End of Life Order Form – English

Symptom Response Kit for End-of-Life Order Form
Please fax your completed form to the appropriate Ontario Health atHome branch:
Central East: 1-855-352-2555 Champlain: 1-800-373-4945 South East: 1-866-839-7299
Timing and placement of the Symptom Response Kit (SRK) requires careful consideration (i.e. prognosis is less than six months; patient expected to deteriorate quickly) with goal of avoiding emergency room visit or hospital admission. Medications in the SRK will expire; therefore, will need to be reviewed and reordered by the physician/Nurse Practitioner (NP) if it remains appropriate. Consider reviewing goals of care and expected home death protocols.