Région de Centre

Clinic Eligibility

COVID-19 Remote Self-Monitor Referral Form

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

Intake and Linking Referral Form

Medical Referral Form

This form is to be completed by the School Staff or Hospital Staff referring student. Submit the completed form (page 1) to the
fax number or email address listed on the form
Please Fax Completed Referral To: (905) 952-2407 or Email To: MHAN@ontariohealthathome.ca
Phone: 905-895-1240 or 416-222-2241 or 1-888-470-2222 Ext. 436525

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.

Palliative Care Resources Guide for Long-Term Care Homes

Palliative Common Referral Form

Palliative Registry Referral Form

POLICY

1. This is a Physician / Nurse Practitioner (NP) order to be implemented by a Registered Nurse (RN) / Registered Practical Nurse (RPN) when
   symptoms require urgent intervention to facilitate a comfortable home death.
2. The attending Physician/NP is to be notified as soon as possible regarding change in patient’s condition and need for ongoing prescription(s).
3. DNR and plan for expected death should be in place.
4. Completed prescription to be FAXED back to Ontario Health atHome at 416-222-6517 or 905-952-2404

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

Telehomecare Referral Form