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500160-Complex-Adult-Seating-Clinic-Referral-2019-08-3.pdf

Please Note: If you require assistance for providing basic needs while attending clinic, a caregiver must accompany you....Date: YYYY/MM/DD Referring Physician (please print):...Time: HH:MM...
https://www.southeasthealthline.ca/pdfs/500160-Complex-Adult-Seating-Clinic-Referral-2019-08-3.pdf

Alz Society Kingston Referral Form.pdf

Relationship to Patient: Caregiver Phone #...Date of Diagnosis:...Diagnosis:...Alzheimer’s Disease Vascular Dementia Frontotemporal Dementia...Lewy-Body Dementia Mixed Dementia MCI...Korsakoff’s...
https://www.southeasthealthline.ca/pdfs/Alz%20Society%20Kingston%20Referral%20Form.pdf

Maple Diabetes Referral Form.pdf

If this patient is not suitable for group programs, please indicate the reason here:...Provider Signature: Date:...☐ Patient has provided consent to share their Personal Health Information with...
https://www.southeasthealthline.ca/pdfs/Maple%20Diabetes%20Referral%20Form.pdf

lgl_health_unit_smoking_resources_for_tobacco_for_general_public.pdf

Has the client considered what supports they would like to use to quit?...No Yes...Yes...See also:...Private Health Insurance...Social Assistance/ODSP...If a client has...extra health...insurance
https://www.southeasthealthline.ca/pdfs/lgl_health_unit_smoking_resources_for_tobacco_for_general_public.pdf

Kingston_Access_Services_Application_Form.pdf

[ ] No the applicant does not require support person travelling with them all the time. ...Note: If the applicant...occasionally requires assistance it is the responsibility of the applicant or a...
https://www.southeasthealthline.ca/pdfs/Kingston_Access_Services_Application_Form.pdf

SMILE PROGRAM

Name: Phone: Relationship: Caregiver: Call Emergency Contact for...DOE/Admission:...Additional Information...**Health Information/Medical Diagnosis:...What services does client currently receive?
https://www.southeasthealthline.ca/pdfs/SMILE%20Referral%20Form%20-%20Ver.8.pdf

von Belleville and Trenton Stroke Exercise Flyer.pdf

A FREE Exercise Program designed for Stroke Survivors of all abilities and their Caregivers!...Belleville...YMCA of Central East Ontario...Belleville Branch...433 Victoria Ave...Wednesdays &...
https://www.southeasthealthline.ca/pdfs/von%20Belleville%20and%20Trenton%20Stroke%20Exercise%20Flyer.pdf

New Client Application Form - Sept 2023 -FINAL.pdf

If I need help, I use the support of local services/programs If I need help, I don’t know where to go...Are you Pregnant? ...No Yes – Please provide expected due date (yy/mm/dd)> YYYY-MM-DD...Do...
https://www.southeasthealthline.ca/pdfs/New%20Client%20Application%20Form%20-%20Sept%202023%20-FINAL.pdf

CPC Patient Information Sheet

a list of support services in your community. ...You...can learn more about support services in your...community by:...Visiting www.ontario.ca/healthcareoptions...Contacting your Home and...
https://www.southeasthealthline.ca/pdfs/Napanee%20Physiotherapy%20and%20Rehabilitation%20-%20OHIP%20Insured%20Physiotherapy%20Information.pdf

Hulpr Rack Card

accompaniments to support a...wide range of needs....More than just a ride!...Dialysis Treatments...Wheelchair Accessible...Hospital Discharges...Medical Appointments...Scheduled in Advance...At...
https://www.southeasthealthline.ca/pdfs/Hulpr-Brochure-Jan2023.pdf