Région d’Érié St-Clair

Assessment service plan form – fillable

Bluewater Water Health emergency referral and treatment form – fillable

Bluewater Water Health inpatient referral and treatment form – fillable

Bluewater Water Health outpatient referral and treatment form – fillable

Children’s Health School Services Program referral form – fillable

Children’s Health School Services Program referral form – fillable in French

Chatham-Kent Health Alliance emergency referral and treatment form – fillable

Chatham-Kent Health Alliance inpatient referral and treatment form – fillable

Chatham-Kent Health Alliance outpatient referral and treatment form – fillable

If required, Telehomecare staff will fax the referral form to the Primary Care Provider to verify and/or provide any relevant information.
Chatham Branch: Fax: 519-351-5842
Sarnia Branch: Fax: 519-337-4331
Windsor Branch: Fax: 519-258-6288

Electrical Stimulation (eSTIM) non-formulary order form – fillable

Electrical Stimulation (eSTIM) referral assessment form – fillable

Equipment rental authorization/order form – fillable

Erie Shores HealthCare emergency referral and treatment form – fillable

Erie Shores HealthCare inpatient referral and treatment form – fillable

Erie Shores HealthCare outpatient referral and treatment form – fillable

First dose parenteral screener form – fillable

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

Hôtel-Dieu Grace Healthcare inpatient referral and treatment form – fillable

Hôtel-Dieu Grace Healthcare inpatient referral and treatment form – fillable

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Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Medical update request form

Medical update request form – wound

Mental Health and Addictions Nursing Program Referral Form for School Board, Community Agencies, etc.

Office Location: 180 Riverview Dr, Chatham
Fax: 1-519-258-6288

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.

Offloading assessment form – fillable

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Providers cupboard usage order form – fillable

Referral and treatment plan form – fillable

Referral and treatment plan pain medication order form – fillable

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

Ontario Health atHome end of life SRK is intended to facilitate timely access to a range of medications to relieve a client’s symptoms in the home on an urgent basis; thereby; potentially avoiding an emergency department and/or acute care admission. Physician orders are indicated below and authorized (signed) by the most responsible
physician (MRP). The nurse can only administer those medications in the kit that have valid signed orders noted on this order form.

Symptom Response Kit (SRK) Request Order Form Windsor

Total contact casting treatment and assessment forms – fillable

Walker assessment eligibility form

Windsor Regional Hospital – Met Campus outpatient referral and treatment form – fillable

Windsor Regional Hospital – Met Campus outpatient URO referral and treatment form – fillable

Windsor Regional Hospital – Met Campus emergency referral and treatment form – fillable

Windsor Regional Hospital – Met Campus inpatient referral and treatment form – fillable

Windsor Regional Hospital – Ouellette Campus inpatient referral and treatment form

Chatham Site – Fax: 519-351-5842
Sarnia Site – Fax: 519-337-4331
Windsor Site – Fax: 519-258-6288

Windsor Regional Hospital – Ouellette Campus outpatient referral and treatment form – fillable

Windsor Regional Hospital – Ouellette Campus emergency referral and treatment form – fillable