North East area

Please fax referral forms to: 705-670-3805
If required, Telehomecare staff will fax the referral form to the Primary Care Provider to verify and/or provide any relevant information.
Updated: June 28, 2024

GENERAL INFORMATION & QUESTIONNAIRE. Updated June 28, 2024

NOTE: A current medication list is recommended with each referral. You may use this form or provide a current medication list using your. own agency-specific/primary care provider’s form if it contains the following information. For additional notes fill out this form. Updated June 28, 2024

This form is additional Notes relating to the Referral for Services form. Updated: June 28, 2024

Referral for Central Venous Access Device (CVAD) Through Regional Cancer Program form. Updated June 2024

*Not a pathway or wound type – use guidelines when NPWT is initiated in conjunction with pathway that is appropriate for wound type.

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.

Medical Equipment and Supply Fax Number: 1-855-697-7358 Right Fax: 3829
*Hospital: Use hospital Ontario Health atHome fax number

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.

The Expected Death in the Home (EDITH) protocol supports end-of-life care based on an individual’s expressed wish to die at home and not to be resuscitated when they stop breathing or their heart stops. An expected death refers to when, in the opinion of a health care team, the patient is irreversibly and irreparably terminally ill; that is, there is no available treatment to restore health, or the patient refuses the available treatment.

Fax: 1-855-697-7358 / Right Fax: 3829
*Hospital: Use hospital Ontario Health atHome fax number

Last Update: December 2024
Fax to OH atHome Office: Regional Equipment & Supplies 1-855-697-7358 or Right Fax: 3829

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*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

Referral for Ontario Health atHome Services in North East

North East – Referral form for administering COVID-19 antivirals in North East community nursing clinics.

Mental Health and Addictions Nursing Program Referral Form

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