Erie St. Clair

Information and Referral

310-2222

(No area code required)

Toll-free:1-888-447-4468
TTY:711 (caller to ask for 1-888-447-4468)
esc.engagement@hccontario.ca

IMPORTANT: DO NOT send any personal health information. This email is not for patient feedback or referrals. Please call us directly at the numbers listed above. We aim to respond within 72 hours, however, this email account is not checked on weekends or statutory holidays.

Visit Erie St. Clair Healthline

Erie St.

Erie St. Clair Office Locations

  • Chatham (Corporate Office)
    180 Riverview Drive
    Chatham, ON, N7M 5Z8
    Fax:  Chatham-Kent – 519-351-5842
  • Sarnia Office
    1150 Pontiac Drive,
    Sarnia, ON, N7S 3A7
    Fax:  Sarnia-Lambton – 519-337-4331
  • Windsor Office
    5415 Tecumseh Road, East,
    Windsor, ON, N8T 1C5
    Fax:  Windsor-Essex – 519-258-6288

Compliments and Concerns?

Please share your feedback with your care coordinator. You may also share compliments or concerns in the following ways:

Email: Esc.PatientRelations@hccontario.ca

Phone: 1-888-447-4468 ext. 7777

Mail: Home and Community Care Support Erie St. Clair Compliments and Concerns
Attn: Patient Relations Specialist
180 Riverview Drive
Chatham, ON N7M 5Z8

Newsroom and Media Relations

Visit our newsroom for more information on news and events. 

For all media-related enquiries, please contact HCCSSmedia@hccontario.ca.

For non-media-related enquiries about Home and Community Care Support Services and to serve you best, please visit the Contact Us page to access additional contact information.

Forms

TitleSummaryRegionLast ModifiedCategoryFile TypeFile SizeLinkhf:doc_tagshf:doc_categorieshf:file_type
Assessment & Service Plan Authorization Private/In-Home School

Assessment service plan form – fillable

June 26, 2023pdf835 KBerie-st-clairformspdf
BWH-ER Referral and Treatment Form

Bluewater Water Health emergency referral and treatment form – fillable

December 19, 2023pdf109 KBerie-st-clairformspdf
BWH-Inpatient Referral and Treatment Form

Bluewater Water Health inpatient referral and treatment form – fillable

June 26, 2023pdf2 MBerie-st-clairformspdf
BWH-Outpatient Referral and Treatment Form

Bluewater Water Health outpatient referral and treatment form – fillable

December 19, 2023pdf102 KBerie-st-clairformspdf
CHSS Referral Form Public Private

Children’s Health School Services Program referral form – fillable

June 26, 2023pdf1 MBerie-st-clairformspdf
CHSS Referral Form Public Private French

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

June 26, 2023pdf129 KBerie-st-clairformspdf
CKHA-ER Referral and Treatment Plan Form

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

December 19, 2023pdf109 KBerie-st-clairformspdf
CKHA-Inpatient Referral and Treatment Plan Form

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

June 26, 2023pdf1 MBerie-st-clairformspdf
CKHA-Outpatient Referral and Treatment Form

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

December 19, 2023pdf113 KBerie-st-clairformspdf
Electrical Stimulation (eSTIM) Non-Formulary Order Form

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

June 26, 2023pdf700 KBerie-st-clairformspdf
Electrical Stimulation (eSTIM) Referral Assessment

Electrical Stimulation (eSTIM) referral assessment form – fillable

June 26, 2023pdf383 KBerie-st-clairformspdf
Equipment Rental Authorization Order Form​

Equipment rental authorization/order form – fillable

June 26, 2023pdf221 KBerie-st-clairformspdf
ESHC-ER Referral and Treatment Form

Erie Shores HealthCare emergency referral and treatment form – fillable

December 19, 2023pdf1 MBerie-st-clairformspdf
ESHC-Inpatient Referral and Treatment Form

Erie Shores HealthCare inpatient referral and treatment form – fillable

July 4, 2023pdf1 MBerie-st-clairformspdf
ESHC-Outpatient Referral and Treatment Form

Erie Shores HealthCare outpatient referral and treatment form – fillable

December 19, 2023pdf107 KBerie-st-clairformspdf
Feeding Respiratory Suction Med. Equipment & Supplies Order Form

September 16, 2022pdf826 KBerie-st-clairformspdf
First Dose Parenteral Screener (ESC)

First dose parenteral screener form – fillable

October 24, 2023pdf429 KBerie-st-clairformspdf
geko Device Eligibility Checklist & Assessment Tool

September 16, 2022pdf826 KBerie-st-clairformspdf
Guidelines for Provision of KCI VAC NPWT

Guidelines for provision of KCI VAC negative pressure wound therapy

July 4, 2023, pdf424 KBerie-st-clairforms guidepdf
HDGH-Inpatient Referral and Treatment Form

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

July 4, 2023pdf1 MBerie-st-clairformspdf
Medical Supply Order Form

September 16, 2022pdf1 MBerie-st-clairformspdf
Medical Update Request Form

Medical update request form

July 4, 2023pdf1 MBerie-st-clairformspdf
Medical Update Request Form – Wound​

Medical update request form – wound

July 4, 2023pdf1 MBerie-st-clairformspdf
MHAN e-Referral Form

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

May 31, 2023htmlerie-st-clairformshtml
Negative Pressure Wound Therapy

Negative pressure wound therapy supply order form – fillable

July 5, 2023pdf208 KBerie-st-clairformspdf
Negative Pressure Wound Therapy – Referral Assessment

Negative pressure wound therapy referral assessment form – fillable

July 5, 2023pdf5 MBerie-st-clairformspdf
Non-formulary Medical Equipment Order Form

Non-formulary medical equipment order form – fillable

July 5, 2023pdf713 KBerie-st-clairformspdf
Non-formulary Medical Supplies Order Form

Non-formulary medical supplies order form – fillable

July 5, 2023pdf96 KBerie-st-clairformspdf
Offloading Shoe Assessment Form

Offloading assessment form – fillable

July 5, 2023pdf359 KBerie-st-clairformspdf
Ostomy Consultation Report

September 16, 2022pdf270 KBerie-st-clairformspdf
Ostomy Supply Order Form

Ostomy supply order form – fillable

August 29, 2023pdf270 KBerie-st-clairformspdf
Providers Cupboard Usage

Providers cupboard usage order form – fillable

July 5, 2023pdf396 KBerie-st-clairformspdf
Referral and Treatment Form

Referral and treatment plan form – fillable

December 19, 2023pdf108 KBerie-st-clairformspdf
Referral and Treatment Form – Pain Medication

Referral and treatment plan pain medication order form – fillable

July 6, 2023pdf795 KBerie-st-clairformspdf
Replenishment Order Form – Nursing

Replenishment order form nursing – fillable

July 6, 2023pdf187 KBerie-st-clairformspdf
Replenishment Order Form – WCS​

Replenishment order form WCS – fillable

July 6, 2023pdf178 KBerie-st-clairformspdf
Symptom Response Kit Request Order Form (Chatham and Sarnia ONLY)

Symptom Response Kit (SRK) Request Order Form Chatham/Sarnia

October 3, 2023pdf49 KBerie-st-clairformspdf
Symptom Response Kit Request Order Form (Windsor ONLY)

Symptom Response Kit (SRK) Request Order Form Windsor

October 3, 2023pdf70 KBerie-st-clairformspdf
Telehomecare Referral Form​​​

Telehomecare referral form – fillable

July 6, 2023pdf639 KBerie-st-clairformspdf
Total Contact Casting Treatment and Assessment

Total contact casting treatment and assessment forms – fillable

August 16, 2023pdf968 KBerie-st-clairformspdf
Walker Assessment Form

Walker assessment eligibility form

July 6, 2023pdf132 KBerie-st-clairformspdf
WRH – Ouellette – ER – First Dose (ESC)

May 2, 2023pdf679 KBerie-st-clairformspdf
WRH Met Campus Outpatient Referral and Treatment Form

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

December 19, 2023pdf1,016 KBerie-st-clairformspdf
WRH-Met Campus Outpatient URO Referral and Treatment Form

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

December 19, 2023pdf113 KBerie-st-clairformspdf
WRH-Met-ER Referral and Treatment Form

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

December 19, 2023pdf109 KBerie-st-clairformspdf
WRH-Met-Inpatient Referral and Treatment Form

September 16, 2022pdf1 MBerie-st-clairformspdf
WRH-Ouellette Campus Outpatient Referral and Treatment Form

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

December 19, 2023pdf102 KBerie-st-clairformspdf
WRH-Ouellette-ER Referral and Treatment Form

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

December 19, 2023pdf109 KBerie-st-clairformspdf
WRH-Ouellette-Inpatient Referral and Treatment Form

September 16, 2022pdf1 MBerie-st-clairformspdf