| Brant (use the Hospice Referral Form and order Outreach Services) | Please use the Hospice Referral Form to request the palliative care outreach services in Brant.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Burlington PCOT Referral Form | To request the services of the Palliative Care Outreach Team in Burlington
| Hamilton Niagara Haldimand Brant | November 8, 2023 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Ceftriaxone Protocol Medical Referral Form | To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| First Dose – IV Medications Form | To order first dose IV medications to be administered to patients in the community. First dose requests may take longer to process and are not appropriate for urgent requirements.
| Hamilton Niagara Haldimand Brant | April 12, 2024 | Forms | pdf | 677 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Haldimand Norfolk PCOT Referral Form | To request the services of the Palliative Care Outreach Teams in Haldimand Norfolk
| Hamilton Niagara Haldimand Brant | December 9, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Hamilton PCOT Referral Form | To request the services of the Palliative Care Outreach Team in Hamilton
| Hamilton Niagara Haldimand Brant | November 8, 2023 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| HNHB Community Paramedicine Communication Form | Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form.
| Hamilton Niagara Haldimand Brant | March 23, 2023 | Forms | pdf | 3 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| HNHB Medical Supplies Catalogue | To order from HNHB’s medical supplies catalogue
| Hamilton Niagara Haldimand Brant | October 18, 2022 | Forms | pdf | 708 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Home Parenteral Nutrition Medical Order Form – Pediatric at McMaster Children’s Hospital | To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital
| Hamilton Niagara Haldimand Brant | October 5, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Hospice Referral Form | To refer a patient to (apply for) hospice and hospice-type services
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| HPG User Access Authorization Form | For hospital partners who use Health Partner Gateway to receive patient referrals.
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Influenza Vaccine Form | To order administration of influenza vaccine
| Hamilton Niagara Haldimand Brant | December 19, 2023 | Forms | pdf | 344 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Iron Infusion Order Form | Hamilton Niagara Haldimand Brant, Iron Infusion order form – To order intravenous iron replacement
| Hamilton Niagara Haldimand Brant | December 13, 2023 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Letter of Understanding – Pronouncement and Certification Death | To identify who will complete pronouncement and certification of death for an expected death at home
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Long-Term Care Home Referral for Service | For Long-Term Care Partners in HNHB. Please complete and fax the Long-Term Care Home Referral for Service form to request one or more of the following services for residents:
• Nursing
• Wound Care
• Speech Language Pathology for Swallowing Assessment
| Hamilton Niagara Haldimand Brant | August 14, 2023 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Margaret’s Place Palliative Overnight Respite Referral Form | To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care
| Hamilton Niagara Haldimand Brant | July 25, 2023 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Medical Order Form – General | To order general medications, including wound care and maintenance for urinary catheters
| Hamilton Niagara Haldimand Brant | April 23, 2024 | Forms | pdf | 650 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Medical Supplies Catalogue | To order from HNHB’s medical supplies catalogue
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 708 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| MHAN Referral Form | Mental Health and Addictions Nursing Program Referral Form.
To request the services of the Mental Health & Additions Nurse, the patient must be:
1. A student registered in school and who is no older than 21 years of age (may include home instruction)
2. In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
3. Aware of and consenting to the referral
Additionally, there must be a clearly defined role for the Mental Health & Addictions Nurse
| Hamilton Niagara Haldimand Brant | May 31, 2023 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Midline Catheter Form | To order midline catheter maintenance
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Milrinone Home Infusion Order Form for Adult Patients | To order Milrinone Infusion Therapy for adult patients
| Hamilton Niagara Haldimand Brant | May 4, 2023 | Forms | pdf | 731 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Negative Pressure Wound Therapy Form | To request negative pressure wound therapy for pressure ulcers, diabetic foot ulcers, arterial ulcers, venous ulcers and surgical wounds
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Negative Pressure Wound Therapy Special Circumstance Form | To request negative pressure wound therapy for patients with special circumstances, e.g. patient has had a wide excision with skin graft or an STSG greater than 2 cm squared
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Niagara PCOT Referral Form | To request the services of the Palliative Care Outreach Team in Niagara.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Nursing Care Centre – Information Handout HNHB | Nursing Care Centre locations throughout HNHB geography.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 490 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Palliative Symptom Response Form | For the management of rapid-onset, unanticipated symptoms for patients nearing end–of-life and no longer able to swallow oral medications. The medication on this order form is limited to support short duration of symptom management (48 hours) until further medications are ordered. Note: See Palliative Care Symptom Response Guidelines for more info on how to use the form.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 993 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Palliative Symptom Response Guideline | Guidelines how to use the Palliative Symptom Response Order Form.
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 3 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Patient and Family Information about Palliative Symptom Response Medication | Information sheet for patients and families.
| Hamilton Niagara Haldimand Brant | December 9, 2022 | Forms, Information Sheet | pdf | 334 KB | | hamilton-niagara-haldimand-brant | forms information-sheet | pdf |
| Pediatric Milrinone Infusion Therapy | To order Milrinone Infusion Therapy for pediatric patients
| Hamilton Niagara Haldimand Brant | May 3, 2023 | Forms | pdf | 407 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Plan of CPR Treatment Form – Palliative Care | To clearly communicate a patient’s plan of care relating to the provision of CPR.
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 733 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Protocol for Central Vascular Access Devices – Pediatrics | To order care relating to vascular access devices in children
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 2 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Protocol for Vascular Access Devices Medical Order Form | To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 1,014 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Protocol Parenteral Nutrition Medical Order Form- Adult Population | To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Referral, Request for Services | Complete the Request for Ontario Health atHome, Hamilton Niagara Haldimand Brant area, services and fax it to the appropriate location. Refer to page 2 of the form for fax numbers.
Primary Care Partners: in addition to using the form above, you may also connect directly with the Care Coordinator aligned with your office/practice.
| Hamilton Niagara Haldimand Brant | June 28, 2024 | Forms | pdf | 206 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Respiratory Therapy Referral Form | For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital
| Hamilton Niagara Haldimand Brant | December 8, 2022 | Forms | pdf | 1 MB | | hamilton-niagara-haldimand-brant | forms | pdf |
| Vancomycin Aminoglycoside Prescription Form | To order IV vancomycin and/or aminoglycosides for patients in the community
| Hamilton Niagara Haldimand Brant | September 20, 2022 | Forms | pdf | 812 KB | | hamilton-niagara-haldimand-brant | forms | pdf |
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