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Diabetes Type 1 Request Treatment_Form

REQUEST AND TREATMENT ORDER FORM DIAGNOSIS : Type 1 Diabetes Pl anned Start Date : REASON FOR REFERRAL TO LHIN: Child/teen requires school support over the lunch hour with: in su lin administration blood glucose monitoring Tim ing: _______________________________________________________________________ Chil d/teen and family to return to Children’s Hospital for ongoing diabetes education and support. If […]

Diabetes Type 1 Request Treatment_Form

REQUEST AND TREATMENT ORDER FORM DIAGNOSIS : Type 1 Diabetes Pl anned Start Date : REASON FOR REFERRAL TO LHIN: Child/teen requires school support over the lunch hour with: in su lin administration blood glucose monitoring Tim ing: _______________________________________________________________________ Chil d/teen and family to return to Children’s Hospital for ongoing diabetes education and support. If […]

HOOPP Beneficiary Designate Form

Beneficiary Designation Form January 2016 Please print clearly using black ink. See the reverse side for important information about this form. Any beneficiary designation you make using this form will revoke any previous beneficiary designation you may have made regarding your HOOPP pension benefits. Member Information first name last name SIN: Tel: Spousal Information If […]

HOOPP Beneficiary Designate Form

Beneficiary Designation Form January 2016 Please print clearly using black ink. See the reverse side for important information about this form. Any beneficiary designation you make using this form will revoke any previous beneficiary designation you may have made regarding your HOOPP pension benefits. Member Information first name last name SIN: Tel: Spousal Information If […]

CW-Central-Region-Temporary-Remote-Work-Policy

Temporary Remote Work Policy Policy Level Approval : Senior Executive Team Policy Category : Human Resources Policy Number : Cross Reference to Othe r policies/legislations/regulations/directives : Occupational Health and Safety Policy Original Date of Approval : November 17 th, 2020 Next Scheduled Year Review: November 17 th, 2021 Policy Applies to: [Tick off all appropriate […]

CW-Central-Region-Temporary-Remote-Work-Policy

Temporary Remote Work Policy Policy Level Approval : Senior Executive Team Policy Category : Human Resources Policy Number : Cross Reference to Othe r policies/legislations/regulations/directives : Occupational Health and Safety Policy Original Date of Approval : November 17 th, 2020 Next Scheduled Year Review: November 17 th, 2021 Policy Applies to: [Tick off all appropriate […]

PCOT Haldimand Norfolk

Haldimand Norfolk Home & Community Care Palliative Care Outreach Team Referral Form Fax: 519-426 -4384 Patient Name ________________________________ ______ HCN ____________________ VC ______ DOB _______________ Address _______________________________________ City __________________ Province ____ _ Postal Code ___________ Patient Phone # ____________________ Contact Name ____________________________ Contact Phone ________________ Preferred Language _______ __________________Gender ____________________ Preferred Pronoun ___________________ Supports Requested […]

Hospice Referral Form

Residence Bed ☐ Day Program ☐ Outreach Team ☐ Visiting Volunteer ☐ Bereavement ☐ Psychosocial Spiritual Hospice Referral Form ☐      Hospice Emmanuel House Carpenter House Hospice Niagara McNally House Bob Kemp Stedman Margaret’s Place Fax # 905-308-8 116 905-631-7 107 905-646-3 860 905-309-6 656 905-318-8 411 519-751-7 527 905-627-6577 Patient […]

Hospice Referral Form

Residence Bed ☐ Day Program ☐ Outreach Team ☐ Visiting Volunteer ☐ Bereavement ☐ Psychosocial Spiritual Hospice Referral Form ☐      Hospice Emmanuel House Carpenter House Hospice Niagara McNally House Bob Kemp Stedman Margaret’s Place Fax # 905-308-8 116 905-631-7 107 905-646-3 860 905-309-6 656 905-318-8 411 519-751-7 527 905-627-6577 Patient […]

HCCSS-Interim-Prorities-Letter-2021-22-FINAL

Ministry of Health Office of the Deputy Premier and Minister of Health 777 Bay Street, 5 th Floor Toronto ON M7A 1N3 Telephone: 416 327-4300 Facsimile: 416 326-1571 www.ontario.ca/healthLetter from the Ministry of Health 181-2021-238 July 1, 2021 Mr. Kenneth Joseph (“Joe”) Parker Board Chair Home and Community Care Support Services via email Dear Mr. […]

HCCSS-Interim-Prorities-Letter-2021-22-FINAL

Ministry of Health Office of the Deputy Premier and Minister of Health 777 Bay Street, 5 th Floor Toronto ON M7A 1N3 Telephone: 416 327-4300 Facsimile: 416 326-1571 www.ontario.ca/healthLetter from the Ministry of Health 181-2021-238 July 1, 2021 Mr. Kenneth Joseph (“Joe”) Parker Board Chair Home and Community Care Support Services via email Dear Mr. […]

TC-CS-THC-Referral-Form

NOTE: The information contained in this form is confi dential. It contains personal health information that is subject to the provisions of the ‘Personal Health Information Protection Act, 2004’. This form and its contents should not be distributed, copied or disclosed to any unauthorized persons. If you have accessed this form in error, please contact […]

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