North Simcoe Muskoka area

TO ALL PALLIATIVE CARE PROVIDERS
(For the purpose of this form, an individual refers to a patient or client)
Your submission of this form will be taken to explicitly mean that you have gained appropriate permission for release of the information contained to the agencies and services to whom you are submitting this. Please also include your Organization’s Release of Information Form, if applicable.

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

MAID Referral

North Simcoe Muskoka Medical Referral Form Adult

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.

Please fax back to ontario health athome 705‐792‐6270

Telehomecare Referral Form