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Medical Order Form: Protocol for Central Vascular Devices (CVAD) For Pediatric Patients at McMaster Children’s Hospital (MCH), Hamilton, ON Toll Free Phone Number: 1-800-810-0000 Name: ______________________________________________________________________________________ ddressW ____________________________________________________________________________________ Postal Code: _________________________________________________________________________________ Phone: _____________________________________________________________________________________ Date of Birth: ________________________________________________________________________________ OHC: _______________________________________________________________________________________ Alternate Phone Number: ______________________________________________________________________ Medical Information Primary Diagnosis and Relevant Health Information: Weight: _________kg Pediatric […]

2023JAN23.V001 Page 1 of 2 356 Oxford Street W est London, ON N6H 1T3 Telephone: 1-800 -811 -5146 Fax: 519 -472 -4045 Enteral Feeding Order Form – Adult PATIENT DETAILS Surname First Name Home Address City Postal Code Health Card Number (HCN) Version Code Date of Birth (YYYY -Month -DD) ENTERAL FEEDING TUBE DETAILS […]

Version 21.001 Medical Order for the Administration of Influenza Vaccine Contact Home and Community Care Support Services HNHB at 1-800 -810- 0000 Patient Name _____________________ ______________ HCN __________ _______ VC _______ DOB _____ _____ ______ Address ________ ________________________________ City _____________ Province __ __ Postal Code ____ _______ Patient Phone # ________________ _ Contact Name […]

Version 21.001 Medical Order for the Administration of Influenza Vaccine Contact Home and Community Care Support Services HNHB at 1-800 -810- 0000 Patient Name _____________________ ______________ HCN __________ _______ VC _______ DOB _____ _____ ______ Address ________ ________________________________ City _____________ Province __ __ Postal Code ____ _______ Patient Phone # ________________ _ Contact Name […]

□ N M k b a e o o e M Tel: 705 721 -8010 Fax: 705 792- 6270 SYMPTOM RELIEF KIT (SRK) FOR PALLIATIVE CARE ‐ ORDER FORM PATIENT INFORMATION Last Name First Name Date of Birth (YYYY/MM/DD) Address Gender Male Female Health Card Number City Postal Code Phone Number Allergies EDITH Protocol […]

[…] fax to 807 -346 -4625 IMPORTANT INFORMATION AND INSTRUCTIONS Yes No Questions 1 -8 MUST be answered ‘Yes’ and questions 9 -10 MUST be answered ‘No’ in order for this referral to be processed. 1. Patient is 18 years of age or older. ☐ ☐ 2. Patient ha s a capable individual (18+ years […]