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“APPLICATION TO REGISTER” For Health Services

Do you have any conditions or diseases that have not been listed? ...If so please list:...Do you take Aspirin or any Blood thinners? ...______________________________________...Have you ever been...
https://www.southeasthealthline.ca/pdfs/BQWCHC_application_referral_form_oral_Health_Services.pdf

rac_lbp_patient_intake_form_march_2020.pdf

 Heart Attack/Coronary Artery Disease No Yes  Ulcer or Stomach Disease No Yes... Heart Failure No Yes  Thyroid Disease No Yes... Lung Disease (e.g. ...asthma,...
https://www.southeasthealthline.ca/pdfs/rac_lbp_patient_intake_form_march_2020.pdf

AMHS-KFLA Fillable Referral Form 2019

AMHS-KFLA...Southeast Ontario Addictions & Mental Health Services Access Form...AMHS-KFLA...This form is to be completed by Primary Health Care and other Health Services Providers...FIELDS MARKED WITH AN...
https://www.southeasthealthline.ca/pdfs/amhs-kfla_addictions_mental_health_kingston_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

New Client Application Form - Sept 2023 -FINAL.pdf

Do you have any chronic diseases, or is there anything you would...like us to know about your health?...No Yes – Please explain below...Have you had a hard time receiving health services and...
https://www.southeasthealthline.ca/pdfs/New%20Client%20Application%20Form%20-%20Sept%202023%20-FINAL.pdf

Client Onboarding Document

Amanda...Welcome...Guide...Picton, ON K0K 2T0...40 Downes Ave...info@hospicepe.com...613-645-4040...We are very honoured to support our residents and their families...during this time. ...We have...
https://www.southeasthealthline.ca/pdfs/Hospice%20Guide.pdf

400292 Initial Assessment ABI OT

barkerd...400127 (2019/02) SIDE 1 OF 1 PERSONAL HEALTH INFORMATION RECORD FORM...P...E...R...S...O...N...L...H...E...L...T...H...N...F...O...R...M...T...IO...N... Physiotherapy  Occupational Therapy
https://www.southeasthealthline.ca/pdfs/pc-Rehabilitation-Therapy-Centre-Outpatient-Referral-2019-02.pdf

400292 Initial Assessment ABI OT

barkerd...400127 (2019/02) SIDE 1 OF 1 PERSONAL HEALTH INFORMATION RECORD FORM...P...E...R...S...O...N...L...H...E...L...T...H...N...F...O...R...M...T...IO...N... Physiotherapy  Occupational Therapy
https://www.southeasthealthline.ca/pdfs/pc_referral_form_seniors_day_rehabilitation_accident_recovery_centre.pdf

400292 Initial Assessment ABI OT

barkerd...400127 (2019/06) SIDE 1 OF 1 PERSONAL HEALTH INFORMATION RECORD FORM...P...E...R...S...O...N...L...H...E...L...T...H...N...F...O...R...M...T...IO...N... Physiotherapy... Speech Language...
https://www.southeasthealthline.ca/pdfs/400127-Rehabilitation-Therapy-Centre-Outpatient-Referral-2019-06.pdf

CHS-External-Referral-Form-March2021.pdf

1 /2...Referral Form...for External Agencies...I. ...REFERRAL DETAILS...The applicant or lawfully authorized substitute decision maker has consented to this referral....Date:...
https://www.southeasthealthline.ca/pdfs/CHS-External-Referral-Form-March2021.pdf