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[…] 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 […]

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 […]

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 […]

[…] 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 […]

Ontario Health atHome, Request for Release of Personal Health Information

[…] 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 […]