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Home and Community Care Support Services Hamilton Niagara Haldimand Brant Palliative Symptom Response Order Form Guideline -2- 2 Purpose The purpose of the Palliative Symptom Response Order Form is the management of rapid-onset, unanticipated symptoms for patients nearing end of life and are no longer able to swallow oral medications . The medication on […]

Home and Community Care Support Services Hamilton Niagara Haldimand Brant Palliative Symptom Response Order Form Guideline -2- 2 Purpose The purpose of the Palliative Symptom Response Order Form is the management of rapid-onset, unanticipated symptoms for patients nearing end of life and are no longer able to swallow oral medications . The medication on […]

[…] 2 prior to infusion and every 30 minutes during infusion ☐ Monitor the patient for at least 30 minu tes and until clinically stable post infusionIron Infusion Order Form Fax completed form to 1-866-655-6402 Name: ______________________________________________________________________________________ Address: ____________________________________________________________________________________ Postal Code: _________________________________________________________________________________ Phone: _____________________________________________________________________________________ Date of Birth: ________________________________________________________________________________ OHC: _______________________________________________________________________________________ Alternate Phone Number: ______________________________________________________________________ ☐ […]

[…] 2 prior to infusion and every 30 minutes during infusion ☐ Monitor the patient for at least 30 minues and until clinically stable post infusion Iron Infusion Order Form Fax completed form to 1-866-655-6402 Name: ______________________________________________________________________________________ Address: ____________________________________________________________________________________ Postal Code: _________________________________________________________________________________ Phone: _____________________________________________________________________________________ Date of Birth: ________________________________________________________________________________ OHC: _______________________________________________________________________________________ Alternate Phone Number: ______________________________________________________________________ ☐ […]

Name : Health Card Number: DOB : Address: CONTINUOUS AMBULATORY DELIVERY DEVICE PATIENT CONTROLLED ANALGESIA (CADD SOLIS – PCA) PRESCRIPTION / ORDER DIAGNOSIS: ALLERGIES: No Yes Please list: In the event of anaphylaxis, community nursing service provider will follow their specific agency policy. PRESCRIPTION/ORDERS CADD Solis PCA Prescription/Orders Route: (Check one) Subcutaneous (S.C) Port-a-cath […]

Name : Health Card Number: DOB : Address: CONTINUOUS AMBULATORY DELIVERY DEVICE PATIENT CONTROLLED ANALGESIA (CADD SOLIS – PCA) PRESCRIPTION / ORDER DIAGNOSIS: ALLERGIES: No Yes Please list: In the event of anaphylaxis, community nursing service provider will follow their specific agency policy. PRESCRIPTION/ORDERS CADD Solis PCA Prescription/Orders Route: (Check one) Subcutaneous (S.C) Port-a-cath […]

Name : Health Card Number: DOB : Address: CONTINUOUS AMBULATORY DELIVERY DEVICE PATIENT CONTROLLED ANALGESIA (CADD SOLIS – PCA) PRESCRIPTION / ORDER DIAGNOSIS: ALLERGIES: No Yes Please list: In the event of anaphylaxis, community nursing service provider will follow their specific agency policy. PRESCRIPTION/ORDERS CADD Solis PCA Prescription/Orders Route: (Check one) Subcutaneous (S.C) Port-a-cath […]

[…] MEDICAL ASSISTANCE IN DYING (MAID ) PRESCRIPTION FORM HCCSS CENTRAL EAST 233 Alden Road Markham, ON L3R 3W6 T: 1-888-313-6988 F: 1-888-287-8577 Page 2 of 2  Order of Administration: Administration Medication Total Quantity Kit 1 Total Quantity Kit 2 Dosage Special Instructions/ Comments Authorized Practitioner Initials STEP 1: ANXIOLYSIS (Benzodiazepine) Midazolam 1mg/mL 10mg […]