Enter “CCAC to Assess” and follow instructions on CCAC hospital posters on each hospital unit
Name:
CECCAC Hospital
Fax Lines
Address:
Postal Code:
Hospital Infusion
Therapy Referral Form
Height:
Phone:
HCN:
Version Code:
Yes
No
Related to:
COPD
Lakeridge Health
Oshawa
Fax:905-444-2516
Diagnosis or a Life
Ongoing Treatment:
Palliative
Curative
Anticipated Prognosis:
<6 months
6-12 months
No Describe:
Midline
PICC
Hickman
Port
SC
Insertion date:
Uncertain
Allergies:
Yes
Yes
Markham Stouffville
Uxbridge Site
Fax:1-844-631-5803
No
Peterborough
Regional Health Centre
Fax:1-855-444-9628
No, if yes, indicate date and time given:
The Scarborough
Hospital – Birchmount
Site
Fax:1-844-631-5804
1st Community Dose: indicate date and time:
IV
Medications
/ Hydration
Name of Medication:
Dosage:
Route:
# of Doses Required:
Frequency:
The Scarborough
Hospital – General
Campus
Fax:1-844-631-5805
# of Days of therapy in Community:
Name of Medication:
Dosage:
Route:
# of Doses Required:
Lakeridge Health Port
Perry
Fax:1-844-631-5803
Ontario Shores
Fax:1-844-631-5803
# of lumen(s):
Alternative routes discussed
1st Dose Given:
Lakeridge Health
Bowmanville
Fax:1-844-631-5802
CHF
Metastatic Spread:
Peripheral
Campbellford
Memorial Hospital
Fax:1-844-631-5800
Northumberland Hills
Hospital
Fax:1-844-631-5801
If Cancer
Line Type
Yes
F
Haliburton Highlands
Health Services
Fax:1-844-709-3779
Other Diagnosis
Pertinent to Care:
No
Limiting Illness
M
Primary Diagnosis:
Blood Pressure:
Telehomecare:
Date of Birth:
(mandatory)
Weight:
Diabetic: Yes
Sex:
Frequency:
Ross Memorial
Hospital
Fax:1-844-631-5806
# of Days of therapy in Community:
For hydration, specify reason:
Rouge Valley Hospital
System – Centenary
Site
Fax:1-844-631-5808
SPECIFIC PHYSICAN ORDERS: (please state)

Infusion/dressing protocols per line type

Saline Flush:

Heparin Flush – specific Physician/Nurse Practitioner order required:

Specify lab orders if required:

Other treatment/therapies/services:
or
per nursing agency protocol
Rouge Valley Hospital
System –
Ajax/Pickering Site
Fax:905-444-2524
Whitby Hospital
Fax:905-444-2518
Note: If unable to restart – patient to Emergency Department
Exceptional circumstances may result in a missed dosage of medication
Unless otherwise indicated, the Community Care Access Centre may determine frequency of visits,
arrange for teaching of patient/caregiver(s)/other regulated staff/reliable person(s).
Ordering Physician /Nurse
Practitioner
Print Name:
Signature:
Date:
CECCAC-CM-620 (01/16)
CPSO/
CNO#
Contact Information for Ordering
Physician
Telephone:
Fax:
After Hours:
Lab results to be sent to
Physician/Nurse Practitioner
Name:
Fax: