Enter “CCAC to Assess” and follow instructions on CCAC hospital posters on each hospital unit
Name:
Address:
Hospital Narcotic Infusion
Therapy Referral Form
Postal Code:
Sex:
M
F
Date of Birth:
Phone:
HCN:
Version Code:
Campbellford
Memorial Hospital
Fax:1-844-631-5800
(mandatory)
Ordering Physician (PRINT):
Allergies:
Primary Diagnosis
Diabetic:
Yes
No
Height:
Lakeridge Health
Bowmanville
Fax:1-844-631-5802
Other Diagnosis
Pertinent to Care:
Medication
Metastatic Spread:
Yes
Lakeridge Health
Oshawa
Fax:905-444-2516
No Describe:
Ongoing Treatment:
Palliative
Curative
Anticipated Prognosis:
<6 months
6-12 months
Morphine
Hydromorphone
Uncertain
Markham
Stouffville Uxbridge
Site
Fax:1-844-631-5803
mg/mL
(Note: The higher the concentration, the smaller the infusion volume to preserve
subcutaneous routes)
sc
Route
Infusion Rate
Other:
(If IV, basal rate volume must be 0.5 mL/hr)
Minimum
mg/hr
Starting
mg/hr
Breakthrough Bolus Minimum
Doses
Starting
Breakthrough Bolus
Interval
mg
Maximum
mg/hr
Maximum
mg
q 15
min prn
Maximum
doses/hr
q
min prn
Maximum
doses/hr
100 mls
Other:
Total Quantity of
Reservoirs
10 (ten)
Other:
The Scarborough
Hospital – General
Campus
Fax:1-844-631-5805
Ross Memorial
Hospital
Fax:1-844-631-5806
ml
Dispense at
each time
2 (two)
Other:
Unless otherwise indicated, the Community Care Access Centre may determine frequency of treatment,
arrange for teaching of patient or other reliable person and/or request assessment from other Community
Care Access Centre disciplines.
Signature:
Date:
CECCAC-CM-635 (01/16)
Rouge Valley
Hospital System –
Centenary Site
Fax:1-844-631-5808
Rouge Valley
Hospital System –
Ajax/Pickering Site
Fax:905-444-2524
OTHER INFORMATION:
Print Name:
Peterborough
Regional Health
Centre
Fax:1-855-444-9628
The Scarborough
Hospital –
Birchmount Site
Fax:1-844-631-5804
mg
Reservoir Size
Ordering Physician /Nurse
Practitioner
Lakeridge Health
Port Perry
Fax:1-844-631-5803
Ontario Shores
Fax:1-844-631-5803
Other:
Added Meds
Concentration
Haliburton
Highlands Health
Services
Fax:1-844-709-3779
Northumberland
Hills Hospital
Fax:1-844-631-5801
Weight:
Blood Pressure:
If Cancer Diagnosis
or a Life Limiting
Illness
CECCAC
Hospital Fax
Lines
CPSO/
CNO#
Contact Information for Ordering
Physician
Telephone:
Fax:
After Hours:
Whitby Hospital
Fax:905-444-2518
Lab results to be sent to
Physician/Nurse Practitioner
Name:
Fax: