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“APPLICATION TO REGISTER” For Health Services

Stroke Diabetes...COPD/Lung Problems Heart Attack...Heart Disease/Heart Surgery/Heart Valve/Heart Murmur/Pacemaker...Infective Endocarditis...Congenital Heart Disease (from birth)...Immune System...
https://www.southeasthealthline.ca/pdfs/BQWCHC_application_referral_form_oral_Health_Services.pdf

rac_lbp_patient_intake_form_march_2020.pdf

 High Cholesterol No Yes  Diabetes No Yes... High Blood Pressure No Yes  Kidney Disease No Yes... Stroke No Yes  Liver Disease No Yes... Heart Attack/Coronary Artery Disease No...
https://www.southeasthealthline.ca/pdfs/rac_lbp_patient_intake_form_march_2020.pdf

Telemedicine Referral Form- revised dec 2018.pdf

Nousheen Kanji...If problems faxing please contact Belleville & Quinte West CHC @ 613-962-0000 x 258 Dec 2023...161 Bridge St. ...West, Belleville ON K8P 1K2 613-962-0000 69 Catherine St Trenton K8V 5K9...
https://www.southeasthealthline.ca/pdfs/Telemedicine%20Referral%20Form-%20revised%20dec%202018.pdf

lanark_county_community_paramedic_program_referral_form.pdf

Administrator...LCPS Community Paramedicine Referral...Date:...Client Profile/Notes to be sent to:...(Primary Care Provider Name & Contact Information including Fax – if applicable)...Patient Information
https://www.southeasthealthline.ca/pdfs/lanark_county_community_paramedic_program_referral_form.pdf

lanark_county_community_paramedic_program_clinical_guidelines.pdf

JScott...Lanark County Paramedic Service Telephone: (613) 205-1021...84 Lorne Street Facsimile: (613) 205-1016...Smiths Falls, Ontario Email: jsteele@lcps.care...K7A 3K8...The Community Paramedic Program...
https://www.southeasthealthline.ca/pdfs/lanark_county_community_paramedic_program_clinical_guidelines.pdf

Kingston_Access_Services_Application_Form.pdf

KAB...Kingston Access Bus – Passenger Application Form – Version 2021-04 Page 1 of 18...• This application form may be used for new applications to Kingston Access Services until December 31, 2022....•...
https://www.southeasthealthline.ca/pdfs/Kingston_Access_Services_Application_Form.pdf

amhs-kfla_addictions_mental_health_kingston_self_referral_form.pdf

ADDICTIONS AND MENTAL HEALTH SERVICES – KFLA...SELF-REFERRAL...Self-Referral Return to Service Referral for a Family Member/Friend...SERVICES REFERRAL SOURCE IF OTHER THAN SELF...What help is needed?
https://www.southeasthealthline.ca/pdfs/amhs-kfla_addictions_mental_health_kingston_self_referral_form.pdf

CPC Patient Information Sheet

BussieDh...Ministry of Health ...Ontario Community Physiotherapy Clinic...Program: Patient Information...Questions? ...Please visit:...www.ontario.ca/physiotherapy...Ontario’s Community Physiotherapy...
https://www.southeasthealthline.ca/pdfs/Napanee%20Physiotherapy%20and%20Rehabilitation%20-%20OHIP%20Insured%20Physiotherapy%20Information.pdf

Comfort Keepers Transportation

Rebecca Phillips...Comforting Transportation:...A Safe and Affordable Experience!...Rather than relying upon family or friends,...Comfort Keepers® can help to provide...convenient, escorted...
https://www.southeasthealthline.ca/pdfs/Comfort%20Keepers%20Transportation.pdf

as_first_link_referral_form.pdf

Date of Referral:...Family dynamics Infectious diseases Infestation/Squalor Pets Physical Environment...Recent hospitalizations Responsive behaviours Smoking Weapons Other:...Person with Dementia Name...
https://www.southeasthealthline.ca/pdfs/as_first_link_referral_form.pdf