Erie St. Clair area

Office Location: 180 Riverview Dr, Chatham
Fax: 1-519-258-6288

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks. Form CS 570 OC 24

Veuillez suivre ces instructions (S’ouvre dans un nouvel onglet)
pour accéder au formulaire.

Formulaire fourni par le ministère des Soins de longue durée en vertu de la Loi de 2021 sur le redressement des soins de longue durée.

Si vous souhaitez être admis dans un foyer de soins de longue durée (SLD), vous devez remplir ce formulaire. Ces renseignements sont requis par Santé à domicile Ontario, le coordonnateur du placement désigné pour les foyers de SLD, afin de déterminer si vous êtes admissible à l’admission. Santé à domicile Ontario peut recueillir d’autres renseignements personnels sur la santé auprès de vos fournisseurs de soins de santé afin de déterminer votre admissibilité. Santé à domicile Ontario peut également utiliser et divulguer les renseignements aux mêmes fins.
Renseignements sur le demandeur

Important Note: Please follow these instructions (opens in a new tab) to access the form.

Form provided by the Ministry of Long-Term Care under the Fixing Long-Term Care Act, 2021.

If you wish to be admitted to a long-term care (LTC) home, you must fill out this form. This information is required by Ontario Health atHome, the designated placement co-ordinator for LTC homes, to determine if you are eligible for admission. Ontario Health atHome may collect additional personal health information from your health care providers
for the purpose of determining your eligibility. Ontario Health atHome may also use and disclose the information for the same purpose.

If required, Telehomecare staff will fax the referral form to the Primary Care Provider to verify and/or provide any relevant information.
Chatham Branch: Fax: 519-351-5842
Sarnia Branch: Fax: 519-337-4331
Windsor Branch: Fax: 519-258-6288

Windsor Regional Hospital – Ouellette Campus inpatient referral and treatment form

Chatham Site – Fax: 519-351-5842
Sarnia Site – Fax: 519-337-4331
Windsor Site – Fax: 519-258-6288

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

Ontario Health atHome end of life SRK is intended to facilitate timely access to a range of medications to relieve a client’s symptoms in the home on an urgent basis; thereby; potentially avoiding an emergency department and/or acute care admission. Physician orders are indicated below and authorized (signed) by the most responsible
physician (MRP). The nurse can only administer those medications in the kit that have valid signed orders noted on this order form.

Mental Health and Addictions Nursing Program Referral Form for School Board, Community Agencies, etc.

Chatham-Kent Health Alliance inpatient referral and treatment form – fillable

Windsor Regional Hospital – Met Campus inpatient referral and treatment form – fillable

Hôtel-Dieu Grace Healthcare inpatient referral and treatment form – fillable

Erie Shores HealthCare inpatient referral and treatment form – fillable

Windsor Regional Hospital – Ouellette Campus emergency referral and treatment form – fillable

Erie Shores HealthCare outpatient referral and treatment form – fillable

Windsor Regional Hospital – Ouellette Campus outpatient referral and treatment form – fillable

Windsor Regional Hospital – Met Campus emergency referral and treatment form – fillable

Windsor Regional Hospital – Met Campus outpatient referral and treatment form – fillable

Walker assessment eligibility form

Symptom Response Kit (SRK) Request Order Form Windsor

Referral and treatment plan form – fillable

Providers cupboard usage order form – fillable

…

Offloading assessment form – fillable

Medical update request form – wound

Medical update request form

Hôtel-Dieu Grace Healthcare inpatient referral and treatment form – fillable

First dose parenteral screener form – fillable

Erie Shores HealthCare emergency referral and treatment form – fillable

Electrical Stimulation (eSTIM) referral assessment form – fillable

Electrical Stimulation (eSTIM) non-formulary order form – fillable

Chatham-Kent Health Alliance outpatient referral and treatment form – fillable

Assessment service plan form – fillable

Bluewater Water Health emergency referral and treatment form – fillable

Bluewater Water Health inpatient referral and treatment form – fillable

Bluewater Water Health outpatient referral and treatment form – fillable

Children’s Health School Services Program referral form – fillable

Chatham-Kent Health Alliance emergency referral and treatment form – fillable

Children’s Health School Services Program referral form – fillable in French

Windsor Regional Hospital – Met Campus outpatient URO referral and treatment form – fillable

Total contact casting treatment and assessment forms – fillable

Referral and treatment plan pain medication order form – fillable