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[…] 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 […]

Symptom Response Kit for End-of -Life Order Form Please fax your completed form to the appropriate Home and Community Care Support Services branch: Central East: 1- 855-352 -2555 Champlain: 1-800-373 -4945 South East: 1-866-839 -7299 Timing and placement of the Symptom Response Kit (SRK) requires careful consideration (i.e. prognosis is less than s ix […]

Symptom Response Kit for End-of -Life Order Form Please fax your completed form to the appropriate Home and Community Care Support Services branch: Central East: 1- 855-352 -2555 Champlain: 1-800-373 -4945 South East: 1-866-839 -7299 Timing and placement of the Symptom Response Kit (SRK) requires careful consideration (i.e. prognosis is less than s ix […]

Page 1 of 4 Version 24-001 Update: September 15, 2024 (DO NOT FILE IN DMS) Infusion and Enteral Supplies Order Form Date: BRN: Patient Name: Ordered By: Name: Agency: Contact (Phone and Ext): Delivery Priority: ☐ Next Day (Delivery by 9:00pm next day. Order must be processed by 5:00pm) ☐ Non-Urgent (Delivery by 9:00pm […]

Name : Health Card Number: DOB : Address: CONTINUOUS AMBULATORY DELIVERYDEVICE PATIENT CONTROLLED ANALGESIA (CADD SOLIS –PCA) PRESCRIPTION / ORDER DIAGNOSIS: ALLERGIES: No Yes Please list: In the event of anaphylaxis, community nursingservice provider will followtheir specific agencypolicy. PRESCRIPTION/ORDERS CADD Solis PCA Prescription/Orders Route:(Check one) Subcutaneous (S.C) Port-a-cath (PAC) Drug: Intravenous(I.V) PICC Concentration*: mg/ml […]

Version 21-001 Palliative Symptom Response Order Form Contact the Home and Communiuty Care Support Services HNHB at 1-800-810-0000 Patient Name ___________________________________________ HCN _________________ VC ______ DOB _______________ Address ____________________________________________ City _____________ Province ______ Postal Code ___________ Patient Phone # ________________ Contact Name _____________________________ Contact Phone ____________________ NB: This order set is intended for a […]

Version 21-001 Palliative Symptom Response Order Form Contact the Home and Communiuty Care Support Services HNHB at 1-800-810-0000 Patient Name ___________________________________________ HCN _________________ VC ______ DOB _______________ Address ____________________________________________ City _____________ Province ______ Postal Code ___________ Patient Phone # ________________ Contact Name _____________________________ Contact Phone ____________________ NB: This order set is intended for a […]

Medical Equipment Vendor Order Trackers VENDOR CONTACT NUMBER ORDER TRACKING Medigas 1-888 -885 -7046 On-Call Emergency: GTA: 800-387 -1517 Western Ontario: 855 -350 -4381 NSM: 844-495 -4435 htps://api.equip.medigas.com/ Search using BRN OMS 613-244 -4679 or To l l-Free: 1 -888 -909 -4679 On-Call Emergency : Central East: 437 -770 -3895 Champlain: 613 -218 -4048 […]

Medical Equipment Vendor Order Trackers VENDOR CONTACT NUMBER ORDER TRACKING Medigas 1-888 -885 -7046 On-Call Emergency: GTA: 800-387 -1517 Western Ontario: 855 -350 -4381 NSM: 844-495 -4435 htps://api.equip.medigas.com/ Search using BRN OMS 613-244 -4679 or To l l-Free: 1 -888 -909 -4679 On-Call Emergency : Central East: 437 -770 -3895 Champlain: 613 -218 -4048 […]