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SE-First-Dose-Parenteral-Med-EN
[…] complete screener if patient has received medication previously with no previous adverse reaction Questions to ask prior to accepting a patient for administration of fi rst dose in the home Yes No Does t he patient have any allergies? If “yes” to allergies, does the patient have any serious allergies/adverse/anaphy lactic reactions to the […]
First Dose Parenteral Medication Screener – English
[…] complete screener if patient has received medication previously with no previous adverse reaction Questions to ask prior to accepting a patient for administration of fi rst dose in the home Yes No Does t he patient have any allergies? If “yes” to allergies, does the patient have any serious allergies/adverse/anaphy lactic reactions to the […]
NE-Referral-for-Services-EN
[…] Medium Large Extra Large Initiate wound -specific clinical pathways Wound Care as follows : Negative Pressure Wound Therapy (NPWT) Foam Type: Cycle: Intermittent Continuous Pressure Setting mmHG: In the event of NPWT failure, please provide back -up orders: As a practitioner, I understand and agree that it is my responsibility to monitor and follow […]
Referral for Services – English
[…] Small Medium Large Extra Large Initiate wound-s pecific clinical pathways Wound Care as follows: Negative Pressure Wound Therapy (NPWT) Foam Type: Cycle: Intermittent Continuous Pressure Setting mmHG: In the event of NPWT failure, please provide back -up orders: As a practitioner, I understand and agree that it is my responsibility to monitor and follow […]
tc-telehomecare-copd-heart-failure-referral-form-en
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 […]
tc-telehomecare-copd-heart-failure-referral-form-en
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 […]
cen-telehomecare-referral-form-en
Note: The information contained in this form is confidential. 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 the owner or sender immediately. V 3.9 C O PD & H eart F ailure T elehom ecare R eferral F orm Please fax referral forms(s) to: PATIENT INFORMATION Referral Date ( D D MM YYYY): ________________ LAST NAME F IR ST NAME DATE OF BIRTH (DD MM YYYY) HEALTH CARD NUMBER (OHIP) VC GENDER ADDRESS CITY POSTAL CODE PRIMARY PHONE […]
cen-telehomecare-referral-form-en
Note: The information contained in this form is confidential. It c ontains 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 the owner or sender immediately. V 3.9 C O PD & H eart F ailure T elehom ecare R eferral F orm Pleas e fa x re fe rra l for ms(s ) to : PATIENT INFORMATION Referral Date ( D D MM YYYY) : ________________ LAST NAME F IRST NAME DATE OF BIRTH (DD MM YYYY) HEALTH CARD […]
nsm-medical-referral-form-child
[…] confidential. Any other delivery, distribution, copying or disc losure is strictly prohibited and is not a waiver of privilege or confidentiality. If you have received this telecommunication in e rror, please notify the sender immediately by telephone at 721 -8010 or 1 -888 -721 – 2222 so that arrangements can be made for its […]
nsm-medical-referral-form-child
[…] Any other delivery, distribution, copying or disc losure is strictly prohibited and is not a waiver of privilege or confidentia lity. If you have received this telecommunication in e rror, please notify the sender immediately by telephone at 721-8010 or 1-888-72 1- 2222 so that arrangements can be made for its destruction or return […]
Request for Release of Personal Health Information – English
Ontario Health atHome, Request for Release of Personal Health Information
cen-intake-and-linking-referral-form-en
[…] Placement bursing butritional Services Occupational Therapy Personal Support (e.g. bathing, dressing) Physiotherapy Social Work Speech Lanuage Pathology Community Linking (e.g. housekeeping, shopping, transportation) Has the patient been in the ER/hospital within the last 14 days? Unknown bo Yes Does the patient have a current cancer diagnosis? Unknown bo Yes Has the patient had any […]