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SMILE PROGRAM

...tion:...Person completing this form:...(Print Name)...Date: Phone Number:...**Ensure Health Information/Medical Diagnosis section is filled out before summitting this form to SMILE...Yes No Yes No
https://www.southeasthealthline.ca/pdfs/SMILE%20Referral%20Form%20-%20Ver.8.pdf

New Client Application Form - Sept 2023 -FINAL.pdf

because of problems with mental health or substance use?...No Yes – Please explain below...Instructions:...1. ...Please complete one form for each applicant...2. ...Complete this fillable form on...
https://www.southeasthealthline.ca/pdfs/New%20Client%20Application%20Form%20-%20Sept%202023%20-FINAL.pdf

Alz Society Kingston Referral Form.pdf

Independent physician Family Health Team (specify which team) ________________...Private PCC Geriatric Outreach S.M.O.L Community Agency...Discipline...General Practitioner Allied Health...
https://www.southeasthealthline.ca/pdfs/Alz%20Society%20Kingston%20Referral%20Form.pdf

Centralized Referral Form

under the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health...Information Protection Act (PHIPA)....Please send your referral form to:...
https://www.southeasthealthline.ca/pdfs/SCIO-centralized-referral-form.pdf

Referral_Form_Wound_Foot_Care.pdf

Name (as it appears on Health Card):_____________________, ________________________, ________...Last First Initial...Preferred Name: _______________________________...Health Card Number:...
https://www.southeasthealthline.ca/pdfs/Referral_Form_Wound_Foot_Care.pdf

Telemedicine Referral Form- revised dec 2018.pdf

It contains personal health information that is subject to the provisions of the Personal Health Information Protection Act, 2004. ...This...form and its contents should not be distributed,...
https://www.southeasthealthline.ca/pdfs/Telemedicine%20Referral%20Form-%20revised%20dec%202018.pdf

CHS-External-Referral-Form-March2021.pdf

CONNECT Mental Health General Support Services...Hearing Care Counselling Settlement Program for Newcomers...Referral for Employment: FAX: 1-855-259-8152 E-MAIL: employmentservices@chs.ca...Job...
https://www.southeasthealthline.ca/pdfs/CHS-External-Referral-Form-March2021.pdf

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

500160 (2019/08) SIDE 1 OF 2 PERSONAL HEALTH INFORMATION RECORD FORM...COMPLEX ADULT SEATING...CLINIC REFERRAL...THIS DEMOGRAPHIC SECTION MUST BE COMPLETED IN FULL...Name:...Street Address:...Home...
https://www.southeasthealthline.ca/pdfs/500160-Complex-Adult-Seating-Clinic-Referral-2019-08-3.pdf

vh_resident_rights_responsibilites_jan2018.pdf

 to care for his or her own health and well-being, as far as he or she is capable;... to inform his or her medical practitioner, as far as he or she is able, about his or her...relevant medical...
https://www.southeasthealthline.ca/pdfs/vh_resident_rights_responsibilites_jan2018.pdf

Community_Brain_Injury_Services_Referral_Form.pdf

Date of Birth: (YYYY/MM/DD) _________________ Health Card Number: _____________________...Version Code & Expiry Date: ______________________...Reason for Referral: How can we help? ...Is client...
https://www.southeasthealthline.ca/pdfs/Community_Brain_Injury_Services_Referral_Form.pdf