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Ontario. Ministry of Health - Ontario Public Drug Programs - Ontario Naloxone Program for Pharmacies
Provincial program to provide naloxone kits through pharmacies, community organizations and provincial correctional facilities * prescription not required, but training is provided * naloxone can help...
https://www.southeasthealthline.ca/displayService.aspx?id=173755
Voir en français
400971-RMandR-Rehabilitation-Referral-Form-2017-03.pdf
At the time of discharge from acute care, acute medical issues have been addressed:
disease
processes...and/or impairments are not precluding participation in rehabilitation program.......
https://www.southeasthealthline.ca/pdfs/400971-RMandR-Rehabilitation-Referral-Form-2017-03.pdf
Referral_Form_Wound_Foot_Care.pdf
who have high risk
chronic
illness and advanced foot problems that do not have any health...insurance coverage, or for those who have exhausted their insurance coverage for wound and...foot care...
https://www.southeasthealthline.ca/pdfs/Referral_Form_Wound_Foot_Care.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
CPC Patient Information Sheet
or
chronic
condition that led to a decline...in function or movement....You must also:...1. ...Have a valid Ontario health card, and...2. ...Be 65 years or older, 19 years or...younger, or any age...
https://www.southeasthealthline.ca/pdfs/Napanee%20Physiotherapy%20and%20Rehabilitation%20-%20OHIP%20Insured%20Physiotherapy%20Information.pdf
Alz Society Kingston Referral Form.pdf
...s:...Alzheimer’s
Disease
Vascular Dementia Frontotemporal Dementia...Lewy-Body Dementia Mixed Dementia MCI...Korsakoff’s Syndrome Dementia due to head trauma...Dementia due to other illness (i.e.
https://www.southeasthealthline.ca/pdfs/Alz%20Society%20Kingston%20Referral%20Form.pdf
PULMONARY REHABILITATION PROGRAM
• No cardiac
disease
which
prevents
partaking in exercise (most undergo Stage II exercise...test at HDH)...• No significant musculoskeletal issues that preclude meaningful participation...
https://www.southeasthealthline.ca/pdfs/SMOL-Referral-Form-1.pdf
AMHS-KFLA Fillable Referral Form 2019
CHRONIC
ILLNESS...PSYCHIATRIC DIAGNOSIS(ES)...ANXIETY PERSONALITY DISORDER...BI-POLAR DISORDER...DEPRESSION SCHIZOPHRENIA...tDUAL DIAGNOSIS (Intellectual Disability & Mental Illness)...COMMENTS:
https://www.southeasthealthline.ca/pdfs/amhs-kfla_addictions_mental_health_kingston_referral_form.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...
https://www.southeasthealthline.ca/pdfs/New%20Client%20Application%20Form%20-%20Sept%202023%20-FINAL.pdf
Maple Diabetes Referral Form.pdf
Maple Diabetes
Prevention
and Education Centre 1036 Princess St, Kingston, Ont, K7L 1H2, ph: 613-531-6086...Maple Diabetes Referral Form...New referrals will be individually triaged and assigned...
https://www.southeasthealthline.ca/pdfs/Maple%20Diabetes%20Referral%20Form.pdf
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