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High or Low Intensity Rehabilitative Referral Form

Form 550 B – Fax Completed form to 519-742-0635

Referrals are coordinated by Ontario Health atHome Waterloo Wellington. Your health care team will be sharing your medical and personal information with Ontario Health atHome WW and the rehabilitative care program. Ontario Health atHome WW will add your name to the waiting list. Your initials and gender will be accessible to Ontario Health atHome WW’s other hospital partners.