Erie St. Clair area

Information and Referral

310-2222

(No area code required)

Toll-free:1-888-447-4468
TTY:711 (caller to ask for 1-888-447-4468)
esc.engagement@ontariohealthathome.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.

Visit Erie St. Clair Healthline

Erie St.

Erie St. Clair Area Office Locations

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

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
Feeding Respiratory Suction Med. Equipment & Supplies Order Form – EN

July 8, 2024pdf909 KBerie-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

, , , , , , , , , , , , , , July 8, 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
geko Device Eligibility Checklist & Assessment Tool – EN

July 8, 2024pdf888 KBerie-st-clairformspdf
Guidelines for Provision of KCI VAC NPWT – EN

Guidelines for provision of KCI VAC negative pressure wound therapy

July 8, 2024, pdf783 KBerie-st-clairforms guidepdf
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 Supply Order Form – EN

July 8, 2024pdf1 MBerie-st-clairformspdf
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
MHAN e-Referral Form

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

May 31, 2023htmlerie-st-clairformshtml
Negative Pressure Wound Therapy – EN

Negative pressure wound therapy supply order form – fillable

July 8, 2024pdf190 KBerie-st-clairformspdf
Negative Pressure Wound Therapy – Referral Assessment – EN

Negative pressure wound therapy referral assessment form – fillable

July 8, 2024pdf5 MBerie-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
Non-formulary Medical Equipment Order Form – EN

Non-formulary medical equipment order form – fillable

July 8, 2024pdf605 KBerie-st-clairformspdf
Non-formulary Medical Supplies Order Form – EN

Non-formulary medical supplies order form – fillable

July 8, 2024pdf180 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
Ostomy Supply Order Form

Ostomy supply order form – fillable

August 29, 2023pdf270 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
Replenishment Order Form – Nursing

Replenishment order form nursing – fillable

July 6, 2023pdf187 KBerie-st-clairformspdf
Replenishment Order Form – WCS​ – EN

Replenishment order form WCS – fillable

July 9, 2024pdf202 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

, , , , , , , , , , , , , , July 8, 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) – EN

Symptom Response Kit (SRK) Request Order Form Chatham/Sarnia

July 9, 2024pdf216 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