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Maple Diabetes Referral Form.pdf

☐ Patient has provided consent to share their Personal Health Information with Maple Diabetes...Fax Referral to Maple Diabetes: 1-888-981-1640...We do not accept referrals for people using...
https://www.southeasthealthline.ca/pdfs/Maple%20Diabetes%20Referral%20Form.pdf

“APPLICATION TO REGISTER” For Health Services

Name of your preferred pharmacy: _____________________Telephone#________________...Location: ____________________________________________...Prescribed Medication Dosage How Often?...1...2...3...4
https://www.southeasthealthline.ca/pdfs/BQWCHC_application_referral_form_oral_Health_Services.pdf

Good Doctors medical clinic at Riverdale Pharmacy .pdf

Riverdale Pharmacy...1-1218 Highway 15, Kingston, K7L0C4...Walk-in clinic every Tuesday, Thursday and Friday...10 am – 4 pm...613-777-1943...By appointments on Mondays 9 am – 6 pm and...Wednesdays...
https://www.southeasthealthline.ca/pdfs/Good%20Doctors%20medical%20clinic%20at%20Riverdale%20Pharmacy%20.pdf

Referral_Form_Wound_Foot_Care.pdf

Client has: □ Diabetes □ Vascular Disease (M.I. .../ Stroke, PVD, etc.) □ Other Chronic Illness...Referral for: □ Open wound/foot ulcer or infection (high priority)...□ Advanced foot problem (i.e....
https://www.southeasthealthline.ca/pdfs/Referral_Form_Wound_Foot_Care.pdf

lgl_health_unit_smoking_resources_for_tobacco_for_general_public.pdf

• Available over the counter at a local pharmacy for those who can afford to pay. ...Sources of free NRT are outlined...Does the client...have Private...Health Insurance?...Is the client on...See...
https://www.southeasthealthline.ca/pdfs/lgl_health_unit_smoking_resources_for_tobacco_for_general_public.pdf

HPE Local Quit Smoking

are a pharmacy client. ...These medications are now...covered under the Ontario Drug Benefit Plan....SMOKERS HELPLINE... Call for free, confidential, one-to-one support...at 1-877-513-5333.......
https://www.southeasthealthline.ca/pdfs/hpe_public_health_local_quit_smoking_support_guide.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