| Brant Palliative Care Outreach Team Referral Form | Referral Form to request the palliative care outreach services in Brant.
| Hamilton Niagara Haldimand Brant | August 29, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Burlington Integrated Palliative Care Outreach Team (IPCOT) Referral Form | Complete the Burlington IPCOT referral form and fax supporting documents to: 905-631-6823
– Medical summary/ health history
– Pertinent diagnostic tests
– Current medication lists
– Pharmacy information
– Consult/ progress notes
– Other notes
| Hamilton Niagara Haldimand Brant | July 26, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Ceftriaxone Protocol Medical Referral Form – EN | To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Community Paramedicine Communication Form | Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form.
| Hamilton Niagara Haldimand Brant | July 11, 2024 | Forms | pdf | 787 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| First Dose – IV Medications Form – EN | To order first dose IV medications to be administered to patients in the community. First dose requests may take longer to process and are not appropriate for urgent requirements.
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 743 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Formulaire de demande pour la divulgation de renseignements personnels | 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
| Central, Central East, Central West, Champlain, Erie St. Clair, Global, Hamilton Niagara Haldimand Brant, Mississauga Halton, North East, North Simcoe Muskoka, North West, South East, South West, Toronto Central, Waterloo Wellington | July 8, 2024 | Forms | pdf | 2 MB | | central central-east central-west champlain erie-st-clair global hamilton-niagara-haldimand-brant mississauga-halton north-east north-simcoe-muskoka north-west south-east south-west toronto-central waterloo-wellington | forms | pdf |
| Haldimand Norfolk Palliative Care Outreach Team Referral Form | To request the services of the Palliative Care Outreach Teams in Haldimand Norfolk
| Hamilton Niagara Haldimand Brant | August 29, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Hamilton Palliative Care Outreach Team Referral Form | To request the services of the Palliative Care Outreach Team in Hamilton
| Hamilton Niagara Haldimand Brant | August 29, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Home Parenteral Nutrition Medical Order Form – Pediatric at McMaster Children’s Hospital | To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital
| Hamilton Niagara Haldimand Brant | October 5, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Hospice Referral Form | To refer a patient to (apply for) hospice and hospice-type services
| Hamilton Niagara Haldimand Brant | September 3, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| HPG User Access Authorization Form – EN | For hospital partners who use Health Partner Gateway to receive patient referrals.
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Influenza Vaccine Form – EN | To order administration of influenza vaccine
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 783 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Information about Palliative Symptom Response Medication – EN | Information sheet for patients and families.
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms, Information Sheet | pdf | 152 KB | | hamilton-niagara-haldimand-brant | forms information-sheet | pdf |
| Iron Infusion Order Form | Hamilton Niagara Haldimand Brant, Iron Infusion order form – To order intravenous iron replacement
| Hamilton Niagara Haldimand Brant | December 13, 2023 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Letter of Understanding – Pronouncement and Certification Death – EN | To identify who will complete pronouncement and certification of death for an expected death at home
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Long-Term Care Home Referral for Service – EN | For Long-Term Care Partners in HNHB. Please complete and fax the Long-Term Care Home Referral for Service form to request one or more of the following services for residents:
• Nursing
• Wound Care
• Speech Language Pathology for Swallowing Assessment
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Margaret’s Place Palliative Overnight Respite Referral Form – EN | To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Medical Order Form – General | To order general medications, including wound care and maintenance for urinary catheters
| Hamilton Niagara Haldimand Brant | July 26, 2024 | Forms | pdf | 705 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Medical Supplies Catalogue | To order from HNHB’s medical supplies catalogue
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 708 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Medical Supplies Catalogue – EN | To order from HNHB’s medical supplies catalogue
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| MHAN Referral Form – EN | Mental Health and Addictions Nursing Program Referral Form.
To request the services of the Mental Health & Additions Nurse, the patient must be:
1. A student registered in school and who is no older than 21 years of age (may include home instruction)
2. In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
3. Aware of and consenting to the referral
Additionally, there must be a clearly defined role for the Mental Health & Addictions Nurse
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Midline Catheter Form – EN | To order midline catheter maintenance
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Milrinone Home Infusion Order Form for Adult Patients – EN | To order Milrinone Infusion Therapy for adult patients
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 786 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Negative Pressure Wound Therapy Referral Form | Note: This form will be effective on July 23, 2024.
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.
| Hamilton Niagara Haldimand Brant | July 17, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Niagara Palliative Care Outreach Team Referral Form | To request the services of the Palliative Care Outreach Team in Niagara.
| Hamilton Niagara Haldimand Brant | August 29, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Nursing Care Centre – Information Handout HNHB | Nursing Care Centre locations throughout HNHB geography.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 490 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Palliative Symptom Response Form | For the management of rapid-onset, unanticipated symptoms for patients nearing end–of-life and no longer able to swallow oral medications. The medication on this order form is limited to support short duration of symptom management (48 hours) until further medications are ordered. Note: See Palliative Care Symptom Response Guidelines for more info on how to use the form.
| Hamilton Niagara Haldimand Brant | July 31, 2024 | Forms | pdf | 992 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Palliative Symptom Response Guideline | Guidelines how to use the Palliative Symptom Response Order Form.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 3 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Pediatric Milrinone Infusion Therapy – EN | To order Milrinone Infusion Therapy for pediatric patients
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Plan of CPR Treatment Form – Palliative Care – EN | To clearly communicate a patient’s plan of care relating to the provision of CPR.
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 772 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Protocol for Central Vascular Access Devices – Pediatrics | To order care relating to vascular access devices in children
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Protocol for Vascular Access Devices Medical Order Form – EN | To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Protocol Parenteral Nutrition Medical Order Form – Adult Population – EN | To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Referral, Request for Services – EN | Complete the Request for Ontario Health atHome, Hamilton Niagara Haldimand Brant area, services and fax it to the appropriate location. Refer to page 2 of the form for fax numbers.
Primary Care Partners: in addition to using the form above, you may also connect directly with the Care Coordinator aligned with your office/practice.
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Request for Release of Personal Health Information | Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004
| Central, Central East, Central West, Champlain, Erie St. Clair, Global, Hamilton Niagara Haldimand Brant, Mississauga Halton, North East, North Simcoe Muskoka, North West, South East, South West, Toronto Central, Waterloo Wellington | August 15, 2024 | Forms | pdf | 2 MB | | central central-east central-west champlain erie-st-clair global hamilton-niagara-haldimand-brant mississauga-halton north-east north-simcoe-muskoka north-west south-east south-west toronto-central waterloo-wellington | forms | pdf |
| Respiratory Therapy Referral Form – EN | For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital
| Hamilton Niagara Haldimand Brant | July 5, 2024 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Vancomycin Aminoglycoside Prescription Form | To order IV vancomycin and/or aminoglycosides for patients in the community
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 812 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
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