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CE-MAID-Prescription-Order-Form

[…] 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 […]

NE-Medical-Supplies-Order-Form-Hospice-EN

Page 1 of 3 Version 25 -001 Update: June 1, 2025 Hospice Suppl y Order Form Date: BRN (if pt level) : Patient Name (if pt level) : Ordered By (name ): Hospice : Contact (Phone and Ext): Delivery Priority (bulk order) : ☐ Next Day (Delivery by 9:00pm next day. Order must be […]

Medical Supplies Order Form – Hospice – English

Page 1 of 3 Version 25 -001 Update: June 1, 2025 Hospice Suppl y Order Form Date: BRN (if pt level) : Patient Name (if pt level) : Ordered By (name ): Hospice : Contact (Phone and Ext): Delivery Priority (bulk order) : ☐ Next Day (Delivery by 9:00pm next day. Order must be […]

OHaH-ME-Order-Trackers-EN

Medical Equipment Vendor Order Trackers Revised: June 5, 2025 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 Toll -Free: 1-888 -909 -4679 On-Call Emergency: Central East: 437 -770 -3895 […]

Medical Equipment Vendor Order Trackers

Medical Equipment Vendor Order Trackers Revised: June 5, 2025 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 Toll -Free: 1-888 -909 -4679 On-Call Emergency: Central East: 437 -770 -3895 […]

cw-infusion-enteral-feeds-supply-order-form-en

Page 1 of 4 Version 24-001 Update: September 15, 2024 (DO NOT FILE IN DMS) Infusion and Enteral Suppl ies 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 […]

cw-infusion-enteral-feeds-supply-order-form-en

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 […]

SE-CADD-Solis-PCA-Order-Form-EN

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 […]

hnhb-palliative-symptom-response-order-form

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 […]

Palliative Symptom Response Order Form

Version 21-001 June 28, 2024 Palliative Symptom Response Order Form Contact Ontario Health atHome 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 one-time short-term […]

Palliative Symptom Response Order Form

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 […]

Palliative Symptom Response Order Form

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 […]