Central West area

*Requests are only for Hospital to Home (H2H) patients already being supported by H2H program within the community
**Hospital based patients are to be initiated as per hospital Ontario Health atHome processes
Please fax completed form to Ontario Health atHome H2H ODB team at 1-877-546-4311

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

Wound Care and General Supply Order Form for Central West area

Urinary Continence Supply Order Form for Central West area

Respiratory Therapy Supply Order Form for Central West area

Ostomy Supply Order Form for Central West area

Infusion and Enteral Supplies Order Form for Central West area

Order form for supplies and equipment needed for Negative Pressure Wound Therapy in the Central West area

This form is to be used for completion of the assessment required under the Fixing Long-Term Care Act, 2021 when a person applies for a determination of eligibility for long-term care home admission. The required assessment is of the applicant’s physical and mental health, and the applicant’s requirements for medical treatment and health care. This assessment must be made by a physician or registered nurse.

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.

Application for School Health Support Services for the PDSB, DPCDSB, UGDSB, YRDSB, YRCDSB, TDSB, TCDSB, and other school boards

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

Mental Health and Addictions Nursing Program Referral Form

Central West – Hospital Medical Referral Form

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

Community Medical Referral Form – Central West

Prescription form for Symptom Management Kit

Central West Palliative Nurse Practitioner Referral Form