Document Category: Forms

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Adult Speech Language Pathology Referral Form

Application for Determination of Eligibility for Long-Term Care – English

Assessment service plan form – fillable

Authorization for Release of Personal Health Information Form

Authorization to Collect, Use, Disclose PHI Form – Bilingual

Please use the Hospice Referral Form to request the palliative care outreach services in Brant.

To request the services of the Palliative Care Outreach Team in Burlington

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

Continuous Ambulatory Delivery Device Patient Controlled Analgesia Prescription Order – South East

Behavioural Supports Outreach Programs (BSOT) general referral form for Toronto Central

To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)

Centralized Diabetes Intake Referral Form

Centralized Intake and Referral Application to Specialty Hospitals – CASS: Toronto Central

Children’s Health School Services Program referral form – fillable

Children’s Health School Services Program referral form – fillable, 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

Clinic Eligibility

Common Palliative Referral Form

Common Palliative Referral Guidelines

Community IV Therapy Venous Access Algorithm

Information sheet about community nursing clinics located throughout HNHB.

Information sheet for patients about Community Nursing Clinics located in Waterloo Wellington

Information sheet for patients about HNHB Community Nursing Clinics in French

Information sheet for patients about Community Nursing Clinics located in Waterloo Wellington ( French)

Community Paramedicine Referral Form

Completed by a Coordinated Bed Access Coordinator (HCCSS staff) for transfers in the rehab bed program

COPD and Heart Failure Telehomecare Referral Form

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COVID-19 Remote Self-Monitor Referral Form

Demande de détermination d’admissibilité pour une admission en foyer de soins de longue durée

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

Electrical Stimulation (eSTIM) referral assessment form – fillable

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Email Consent and Use Form – French

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

Family Managed Home Care Application Form – English

Family Managed Home Care Application Form – French

Feedback Form – How did we do today?

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To order first dose IV medications to be administered to patients in the community

First Dose Parenteral Administration Form

First Dose Parenteral Medication Screener – South East

First dose parenteral screener form – fillable

Formulaire de demande/consentement pour la divulgation de renseignements personnels en vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé

Request form under the Freedom of Information and Protection of Privacy Act

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Guidelines for provision of KCI VAC negative pressure wound therapy

To request the services of the Palliative Care Outreach Teams in Haldimand Norfolk

To request the services of the Palliative Care Outreach Team in Hamilton

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

Health Assessment Form Fillable – English

Health Assessment Form Fillable – French

Hip and Knee Referral Form

Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form.

To order from HNHB’s medical supplies catalogue

Complete the Request for Home and Community Care Support Services HNHB form 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.

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Completed by Primary care Physician to request Home Care services. Patient/Families may also print this referral form to bring to an appointment for completion.

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To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital

Completed by a Primary Care Physician

To refer a patient to (apply for) hospice and hospice-type services

Hospital Infusion Therapy Referral Form

Hospital Narcotic Infusion Therapy Referral Form

Hospital Request for Assessment Form

For hospital partners who use Health Partner Gateway to receive patient referrals.

To order administration of influenza vaccine

Referral form for administering COVID-19 antivirals in South East community nursing clinics.

Infusion Therapy – IV Remdesivir Referral Form

Referral form for administering COVID-19 antivirals in North West community.

Remdesivir Infusion Referral Form

Referral form for administering COVID-19 antivirals in Toronto Central community nursing clinics.

Referral form for administering COVID-19 antivirals in North East community nursing clinics.

Infusion Therapy Referral Form

Infusion Therapy Venous Access Referral Form

Intake and Linking Referral Form

Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form

To order intravenous iron replacement

South East IV therapy/venous access management medical orders

To identify who will complete pronouncement and certification of death for an expected death at home

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Long-Term Care Home Crisis Choice List – Bilingual

You may choose up to five (5) long-term care homes.

Formulaire de choix de foyer de soins de longue durée. Vous pouvez choisir jusqu’à cinq (5) foyers de soins de longue durée.

Long-Term Care Home Choice List – English

Long-Term Care Home Choice List – French

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

Long-Term Care Home Short Stay Interim Choice List – English

Long-Term Care Home Short Stay Interim Choice List – French

Long-Term Care Home Short Stay Respite Choice List – English

Long-Term Care Home Short Stay Respite Choice List – French

Long-term care counselling checklist for community patients.

Patients dans la communauté – Liste de vérification des conseils pour admission en soins de longue durée

Long-term care counselling checklist for hospital patients.

Liste de vérification pour les patients hospitalisés – Renseignements sur les soins de longue durée

Fax cover sheet that can be used to accompany MAID referral document

Completed by a Primary Care Physician

South East Medical Assistance in Dying Assessment Record

Central East Medical Assistance in Dying Prescription Order Form

South East Medical Assistance in Dying Prescription/Order Form

South East Medical Assistance in Dying Procedural Record

MAID Referral

To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care

To order nursing and IV starts for MAiD

Home and Community Care Support Services South East Medical Order Form

To order general medications, including wound care and maintenance for urinary catheters

To order care relating to parenteral therapy

Medical Referral Form

Medical Referral Form

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North Simcoe Muskoka Medical Referral Form Adult

Medical Referral Form Child

North Simcoe Muskoka Medical Referral Guidelines PCP Adult – English

Medical Referral Guidelines PCP Children – English

Medical Referral Infusions Pain and Symptom Management

To order from HNHB’s medical supplies catalogue

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Medical update request form

Medical update request form – wound

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

Mental Health and Addictions Nursing Program Referral Form – Completed by a School Social Worker (SW) or Child/Youth Worker (CYW), Primary Care Physician, Psychiatrist, CAIP (GRH staff in the inpatient mental health program)

Mental Health and Addictions Nursing Program Referral Form

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

South East Mental Health and Addiction Nursing referral form

Mental Health and Addictions Nursing Program Referral Form

Mental Health and Addictions Nursing Program Referral Form.

Mental Health and Addictions Nursing Program Referral Form

Mental Health and Addictions Nursing Program referral form – Viamonde School Board

Formulaire d’orientation des soins infirmiers en santé mentale et toxicomania – Conseil Scolaire Viamonde

Mental Health and Addictions Nursing program referrals from hospitals

Mental Health and Addiction Nursing (MHAN) Program referral form – Conseil scolaire catholique MonAvenir

Mental Health and Addiction Nursing (MHAN) Program referral form – Toronto Catholic District School Board

Mental Health and Addiction Nursing (MHAN) Program referral form – Toronto District School Board

Mental Health and Addictions Nursing Program Referral Form

Mental Health and Addictions Nursing Program Referral Form

Mental Health and Addictions Nursing Program Self Referral Form

To order midline catheter maintenance

To order Milrinone Infusion Therapy for adult patients

Narcotic Infusion Therapy Referral Form

Negative pressure wound therapy supply order form – fillable

Negative pressure wound therapy referral assessment form – fillable

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To request negative pressure wound therapy for pressure ulcers, diabetic foot ulcers, arterial ulcers, venous ulcers and surgical wounds

Can be completed by a Primary Care Physician, Nurse Practitioner, NSWOC(Nurse specializing in wound, ostomy and continence care), or CNS (clinical Nurse specialist)

South East Negative Pressure Wound Therapy Order form cannot be initiated without negative pressure setting, therapy setting and contingency dressing orders.

Negative Pressure Wound Therapy Prescription Form

To request negative pressure wound therapy for patients with special circumstances, e.g. patient has had a wide excision with skin graft or an STSG greater than 2 cm squared

To request the services of the Palliative Care Outreach Team in Niagara.

Non-formulary medical equipment order form – fillable

Non-formulary medical supplies order form – fillable

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Nursing Care Centre locations throughout HNHB geography.

Offloading assessment form – fillable

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Ostomy supply order form – fillable

Palliative Care Common Referral Form FAQ

Palliative Care Resources Guide for Long-Term Care Homes

Completed by a community or hospital care coordinator (HCCSS staff) along with the patient/family for EOL(end of life) care

Palliative Care Referral Form

Palliative Care SBAR Communication Tool for Nurses in the South East

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Palliative Common Referral Form

Central West Palliative Nurse Practitioner Referral Form

Palliative Registry Referral Form

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Palliative Symptom Relief Kit

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.

Guidelines how to use the Palliative Symptom Response Order Form.

Completed by a Primary Care Physician or Registered Dietician

Information sheet for patients and families.

Patient Appeal Form

To order Milrinone Infusion Therapy for pediatric patients

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To clearly communicate a patient’s plan of care relating to the provision of CPR.

To order care relating to vascular access devices in children

To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)

To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients

Providers cupboard usage order form – fillable

Complete this form to refer patients to approved regional providers for offloading footwear

Referral and treatment plan form – fillable

Referral and treatment plan pain medication order form – fillable

Referral for Central Venous Access Device (CVAD) Through Regional Cancer Program form

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Champlain referral form for home and community care services

Referral Form for Home and Community Care Services

Home and Community Care Support Services South East referrals from hospital

Regional Palliative Consultation Team Referral Form

Replenishment order form nursing – fillable

Replenishment order form WCS – fillable

Request For Assessment Form

Request For Assessment Form – French

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

For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital

Completed by Retirement Home(RH) or HCCSS staff to outline services that a patient is currently receiving or may require if moving to a Retirement Home setting

Home and Community Care Support Services South East service request/referral form

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South West Community nursing clinic fact sheet for prescribers

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South West MAID referral form

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Timing and placement of the Symptom Response Kit requires careful consideration with a goal of avoiding emergency room visit or hospital admission.

Request for Type 1 Diabetes Treatment Order

Information about community nursing clinics located throughout South West

Information about community nursing clinics located throughout South West (French)

Request for palliative services in the community

Completed by Retirement Home staff when requesting a Swallowing Assessment

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Home and Community Support Services Mississauga Halton Symptom Management Kit Prescription/Order Form

Symptom Relief Kit (SRK) For Palliative Care ‐ Order Form

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

Symptom Response Kit for End-of-Life Order Form – Champlain

Symptom Response Kit (SRK) Request Order Form Chatham/Sarnia

Symptom Response Kit (SRK) Request Order Form Windsor

Telehomecare COPD HF Referral Form

Telehomecare COVID-19 Remote Monitoring Referral Form – FR

Telehomecare Referral Form

Telehomecare referral form – fillable

Telehomecare Referral Form

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This document is created to validate DL after changing the login URL

Total contact casting treatment and assessment forms – fillable

To order IV vancomycin and/or aminoglycosides for patients in the community

Walker assessment eligibility form

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Windsor Regional Hospital – Met Campus out patient referral and treatment form – fillable

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

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

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

Application for HCCSS staff to be completed for a patient moving from Acute Care to a Rehab bed in the WW region.