Erie St. Clair area

Erie St. Clair Area Office Locations

  • Chatham
    180 Riverview Drive
    Chatham, ON, N7M 5Z8
    Fax:  519-351-5842 (Chatham-Kent)
  • Sarnia Office
    1150 Pontiac Drive,
    Sarnia, ON, N7S 3A7
    Fax:  519-337-4331 (Sarnia-Lambton)
  • Windsor Office
    5415 Tecumseh Road, East,
    Windsor, ON, N8T 1C5
    Fax:  519-258-6288 (Windsor-Essex)

Compliments and Concerns?

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

Email: Esc.PatientRelations@ontariohealthathome.ca

Phone: 1-888-447-4468 ext. 7777

Mail: Ontario Health atHome
Attn: Patient Relations Specialist
180 Riverview Drive
Chatham, ON N7M 5Z8

Newsroom and Media Relations

Visit our newsroom for more information on news and events. 

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

For non-media-related enquiries, please visit the Contact Us page to access additional contact information.

Forms

TitleSummaryRegionLast ModifiedCategoryFile TypeFile SizeLinkhf:doc_tagshf:doc_categorieshf:file_type
Assessment & Service Plan Authorization Private/In-Home School – EN

Assessment service plan form – fillable

July 8, 2024pdf895 KBerie-st-clairformspdf
BWH-ER Referral and Treatment Form – EN

Bluewater Water Health emergency referral and treatment form – fillable

July 8, 2024pdf1 MBerie-st-clairformspdf
BWH-Inpatient Referral and Treatment Form – EN

Bluewater Water Health inpatient referral and treatment form – fillable

July 8, 2024pdf2 MBerie-st-clairformspdf
BWH-Outpatient Referral and Treatment Form – EN

Bluewater Water Health outpatient referral and treatment form – fillable

July 8, 2024pdf1 MBerie-st-clairformspdf
CHSS Referral Form Public Private – EN

Children’s Health School Services Program referral form – fillable

July 8, 2024pdf1 MBerie-st-clairformspdf
CHSS Referral Form Public Private FR

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

July 8, 2024pdf107 KBerie-st-clairformspdf
CKHA-ER Referral and Treatment Plan Form – EN

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

July 8, 2024pdf1 MBerie-st-clairformspdf
CKHA-Inpatient Referral and Treatment Plan Form

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

July 19, 2024pdf1 MBerie-st-clairformspdf
CKHA-Outpatient Referral and Treatment Form – EN

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

July 8, 2024pdf1 MBerie-st-clairformspdf
Electrical Stimulation (eSTIM) Non-Formulary Order Form

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

July 8, 2024pdf605 KBerie-st-clairformspdf
Electrical Stimulation (eSTIM) Referral Assessment – EN

Electrical Stimulation (eSTIM) referral assessment form – fillable

July 8, 2024pdf561 KBerie-st-clairformspdf
Equipment Rental Authorization Order Form​ – EN

Equipment rental authorization/order form – fillable

July 8, 2024pdf338 KBerie-st-clairformspdf
ESHC-ER Referral and Treatment Form – EN

Erie Shores HealthCare emergency referral and treatment form – fillable

July 8, 2024pdf1 MBerie-st-clairformspdf
ESHC-Inpatient Referral and Treatment Form

Erie Shores HealthCare inpatient referral and treatment form – fillable

July 19, 2024pdf1 MBerie-st-clairformspdf
ESHC-Outpatient Referral and Treatment Form – EN

Erie Shores HealthCare outpatient referral and treatment form – fillable

July 9, 2024pdf1 MBerie-st-clairformspdf
First Dose Parenteral Screener (ESC) – EN

First dose parenteral screener form – fillable

July 8, 2024pdf454 KBerie-st-clairformspdf
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

, , , , , , , , , , , , , , September 19, 2024pdf229 KBcentral 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-wellingtonformspdf
HDGH-Inpatient Referral and Treatment Form

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

July 19, 2024pdf1 MBerie-st-clairformspdf
HDGH-Inpatient Referral and Treatment Form – EN

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

July 8, 2024pdf1 MBerie-st-clairformspdf
Medical Equipment & Supplies Exceptional Item Request Form

September 25, 2024, pdf2 MBerie-st-clairforms medical-equipment-and-suppliespdf
Medical Supplies Order Form – Infusion and Enteral Feed

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

*Hospital: Use hospital Ontario Health atHome fax number

September 25, 2024, pdf185 KBerie-st-clairforms medical-equipment-and-suppliespdf
Medical Supplies Order Form – Ostomy Supply

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

*Hospital: Use hospital Ontario Health atHome fax number

September 25, 2024, pdf158 KBerie-st-clairforms medical-equipment-and-suppliespdf
Medical Supplies Order Form – Respiratory Therapy

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

*Hospital: Use hospital Ontario Health atHome fax number

September 25, 2024, pdf155 KBerie-st-clairforms medical-equipment-and-suppliespdf
Medical Supplies Order Form – Urinary Continence

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

*Hospital: Use hospital Ontario Health atHome fax number

September 25, 2024, pdf155 KBerie-st-clairforms medical-equipment-and-suppliespdf
Medical Supplies Order Form – Wound Care and General Supply

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

*Hospital: Use hospital Ontario Health atHome fax number

September 25, 2024, pdf195 KBerie-st-clairforms medical-equipment-and-suppliespdf
Medical Update Request Form – EN

Medical update request form

July 8, 2024pdf1 MBerie-st-clairformspdf
Medical Update Request Form – Wound​ – EN

Medical update request form – wound

July 8, 2024pdf1 MBerie-st-clairformspdf
Mental Health and Addictions Nurses (MHAN) e-Referral Form

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

July 26, 2024htmlerie-st-clairformshtml
Negative Pressure Wound Therapy – Supplies & Equipment Order Form

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

July 25, 2024pdf95 KBerie-st-clairformspdf
Negative Pressure Wound Therapy Referral Form

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.

July 15, 2024pdf105 KBerie-st-clairformspdf
Offloading Shoe Assessment Form – EN

Offloading assessment form – fillable

July 8, 2024pdf390 KBerie-st-clairformspdf
Ostomy Consultation Report

July 8, 2024pdf157 KBerie-st-clairformspdf
Providers Cupboard Usage – EN

Providers cupboard usage order form – fillable

July 9, 2024pdf481 KBerie-st-clairformspdf
Referral and Treatment Form

Referral and treatment plan form – fillable

July 9, 2024pdf1 MBerie-st-clairformspdf
Referral and Treatment Form – Pain Medication

Referral and treatment plan pain medication order form – fillable

July 6, 2023pdf795 KBerie-st-clairformspdf
Request for Release of Personal Health Information

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

, , , , , , , , , , , , , , September 19, 2024pdf2 MBcentral 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-wellingtonformspdf
Symptom Response Kit Request Order Form – Chatham and Sarnia Only

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.

July 31, 2024pdf88 KBerie-st-clairformspdf
Symptom Response Kit Request Order Form (Windsor ONLY) – EN

Symptom Response Kit (SRK) Request Order Form Windsor

July 9, 2024pdf278 KBerie-st-clairformspdf
Telehomecare Referral Form​​​ – EN

Telehomecare referral form – fillable

July 9, 2024pdf716 KBerie-st-clairformspdf
Total Contact Casting Treatment and Assessment

Total contact casting treatment and assessment forms – fillable

August 16, 2023pdf968 KBerie-st-clairformspdf
Walker Assessment Form – EN

Walker assessment eligibility form

July 9, 2024pdf209 KBerie-st-clairformspdf
WRH Met Campus Outpatient Referral and Treatment Form – EN

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

July 9, 2024pdf1 MBerie-st-clairformspdf
WRH-Met Campus Outpatient URO Referral and Treatment Form

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

December 19, 2023pdf113 KBerie-st-clairformspdf
WRH-Met-ER Referral and Treatment Form – EN

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

July 9, 2024pdf1 MBerie-st-clairformspdf
WRH-Met-Inpatient Referral and Treatment Form

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

July 19, 2024pdf1 MBerie-st-clairformspdf
WRH-Ouellette Campus Outpatient Referral and Treatment Form – EN

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

July 9, 2024pdf1 MBerie-st-clairformspdf
WRH-Ouellette-ER Referral and Treatment Form – EN

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

July 19, 2024pdf1 MBerie-st-clairformspdf
WRH-Ouellette-Inpatient Referral and Treatment Form

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

July 19, 2024pdf1 MBerie-st-clairformspdf