Hamilton Niagara Haldimand Brant

Information and Referral

310-2222

(no area code required)

Toll-free:1-800-810-0000

Fax: 1-866-655-6402 (for patient-related information and referrals)

TTY:711

Email:access@hccontario.ca
IMPORTANT: DO NOT send any personal health information. This email is not for patient feedback or referrals. Please call us directly at the numbers listed above. We aim to respond within 72 hours, however, this email account is not checked on weekends or statutory holidays.

Connect with Your Regional Healthline

Hamilton Niagara Haldimand Brant Local Offices

Hamilton (Corporate Office)
211 Pritchard Road,
Unit 1,
Hamilton, ON, L8J 0G5
Niagara
149 Hartzel Road,
St. Catharines, ON, L2P 1N6
Haldimand-Norfolk / Brant
195 Henry Street,
Unit 4, Building 4,
Brantford, ON, N3S 5C9
Burlington
440 Elizabeth Street,
4th Floor,
Burlington, ON, L7R 2M1

Compliments and Concerns?

Please share your feedback with your care coordinator. You may also share compliments or concerns in the following ways:

Email: hnhb.patientrelations@hccontario.ca

Phone: 1-866-790-4642 ext. 3883

Mail: Attention – Manager, Patient Relations
211 Pritchard Road, Unit 1, Hamilton ON L8J 0G5

Newsroom and Media Relations

Visit our newsroom for more information on news and events.

For all media-related enquiries, please contact HCCSSmedia@hccontario.ca.

Forms

Title	Summary	Categories
Brant (use the Hospice Referral Form and order Outreach Services)	Please use the Hospice Referral Form to request the palliative care outreach services in Brant.	Forms
Burlington PCOT Referral Form	To request the services of the Palliative Care Outreach Team in Burlington	Forms
Ceftriaxone Protocol Medical Referral Form	To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)	Forms
Community Nursing Clinics	Information sheet about community nursing clinics located throughout HNHB.	Forms, Information Sheet
Community Nursing Clinics – Patient Handout FR	Information sheet for patients about HNHB Community Nursing Clinics in French	Forms, Information Sheet
First Dose – IV Medications Form	To order first dose IV medications to be administered to patients in the community	Forms
Haldimand Norfolk PCOT Referral Form	To request the services of the Palliative Care Outreach Teams in Haldimand Norfolk	Forms
Hamilton PCOT Referral Form	To request the services of the Palliative Care Outreach Team in Hamilton	Forms
HNHB Community Paramedicine Communication Form	Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form.	Forms
HNHB Medical Supplies Catalogue	To order from HNHB’s medical supplies catalogue	Forms
HNHB Referral Form – EN	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.	Forms
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	Forms
Hospice Referral Form	To refer a patient to (apply for) hospice and hospice-type services	Forms
HPG User Access Authorization Form	For hospital partners who use Health Partner Gateway to receive patient referrals.	Forms
Influenza Vaccine Form	To order administration of influenza vaccine	Forms
Iron Infusion Order Form	To order intravenous iron replacement	Forms
Letter of Understanding – Pronouncement and Certification Death	To identify who will complete pronouncement and certification of death for an expected death at home	Forms
Long-Term Care Home Referral for Service	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	Forms
Margaret’s Place Palliative Overnight Respite Referral Form	To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care	Forms
Medical Assistance in Dying Medical Order Form	To order nursing and IV starts for MAiD	Forms
Medical Order Form – General	To order general medications, including wound care and maintenance for urinary catheters	Forms
Medical Supplies Catalogue	To order from HNHB’s medical supplies catalogue	Forms
MHAN 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	Forms
Midline Catheter Form	To order midline catheter maintenance	Forms
Milrinone Home Infusion Order Form for Adult Patients	To order Milrinone Infusion Therapy for adult patients	Forms
Negative Pressure Wound Therapy Form	To request negative pressure wound therapy for pressure ulcers, diabetic foot ulcers, arterial ulcers, venous ulcers and surgical wounds	Forms
Negative Pressure Wound Therapy Special Circumstance 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	Forms
Niagara PCOT Referral Form	To request the services of the Palliative Care Outreach Team in Niagara.	Forms
Nursing Care Centre – Information Handout HNHB	Nursing Care Centre locations throughout HNHB geography.	Forms
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.	Forms
Palliative Symptom Response Guideline	Guidelines how to use the Palliative Symptom Response Order Form.	Forms
Patient and Family Information about Palliative Symptom Response Medication	Information sheet for patients and families.	Forms, Information Sheet
Pediatric Milrinone Infusion Therapy	To order Milrinone Infusion Therapy for pediatric patients	Forms
Plan of CPR Treatment Form – Palliative Care	To clearly communicate a patient’s plan of care relating to the provision of CPR.	Forms
Protocol for Central Vascular Access Devices – Pediatrics	To order care relating to vascular access devices in children	Forms
Protocol for Vascular Access Devices Medical Order Form	To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)	Forms
Protocol Parenteral Nutrition Medical Order Form- Adult Population	To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients	Forms
Respiratory Therapy Referral Form	For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital	Forms
Vancomycin Aminoglycoside Prescription Form	To order IV vancomycin and/or aminoglycosides for patients in the community	Forms

Title

Summary

Categories

Link

Brant (use the Hospice Referral Form and order Outreach Services)

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

Forms

Burlington PCOT Referral Form

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

Forms

Ceftriaxone Protocol Medical Referral Form

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

Forms

Community Nursing Clinics

Information sheet about community nursing clinics located throughout HNHB.

Forms, Information Sheet

Community Nursing Clinics – Patient Handout FR

Information sheet for patients about HNHB Community Nursing Clinics in French

Forms, Information Sheet

First Dose – IV Medications Form

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

Forms

Haldimand Norfolk PCOT Referral Form

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

Forms

Hamilton PCOT Referral Form

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

Forms

HNHB Community Paramedicine Communication Form

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

Forms

HNHB Medical Supplies Catalogue

To order from HNHB’s medical supplies catalogue

Forms

HNHB Referral Form – EN

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.

Forms

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

Forms

Hospice Referral Form

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

Forms

HPG User Access Authorization Form

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

Forms

Influenza Vaccine Form

To order administration of influenza vaccine

Forms

Iron Infusion Order Form

To order intravenous iron replacement

Forms

Letter of Understanding – Pronouncement and Certification Death

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

Forms

Long-Term Care Home Referral for Service

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

Forms

Margaret’s Place Palliative Overnight Respite Referral Form

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

Forms

Medical Assistance in Dying Medical Order Form

To order nursing and IV starts for MAiD

Forms

Medical Order Form – General

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

Forms

Medical Supplies Catalogue

To order from HNHB’s medical supplies catalogue

Forms

MHAN 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

Forms

Midline Catheter Form

To order midline catheter maintenance

Forms

Milrinone Home Infusion Order Form for Adult Patients

To order Milrinone Infusion Therapy for adult patients

Forms

Negative Pressure Wound Therapy Form

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

Forms

Negative Pressure Wound Therapy Special Circumstance 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

Forms

Niagara PCOT Referral Form

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

Forms

Nursing Care Centre – Information Handout HNHB

Nursing Care Centre locations throughout HNHB geography.

Forms

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.

Forms

Palliative Symptom Response Guideline

Guidelines how to use the Palliative Symptom Response Order Form.

Forms

Patient and Family Information about Palliative Symptom Response Medication

Information sheet for patients and families.

Forms, Information Sheet

Pediatric Milrinone Infusion Therapy

To order Milrinone Infusion Therapy for pediatric patients

Forms

Plan of CPR Treatment Form – Palliative Care

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