Waterloo Wellington area

Waterloo Wellington Area Office Locations

  • Waterloo
    141 Weber Street South, 
    Waterloo, ON, N2J 2A9
    Fax:  519-883-5555 (Waterloo Region)
  • Cambridge
    73 Water Street North,
    Suite 501,
    Cambridge, ON,   N1R 7L6
    Fax:  519-623-5068 (Cambridge – North Dumfries)
  • Guelph
    1 Stone Road West, 
    Guelph, ON, N1G 4Y2
    Fax:  519-823-8682 (Guelph | Wellington County)

Compliments and Concerns?

Please share your feedback with your care coordinator. You may also share compliments or concerns in the following ways:

Email: patient.relations.ww@ontariohealthathome.ca

Phone: 1-888-883-3313 ext. 5443 

Mail: Ontario Health atHome
Compliments and Concerns
Attn: Manager, Patient Relations
141 Weber Street South  
Waterloo, ON 
N2J 2A9 

Newsroom and Media Relations

Visit our newsroom for more information on news and events. 

For all media-related enquiries, please contact media@ontariohealthathome.ca.

For non-media-related enquiries, please visit the Contact Us page to access additional contact information.

Forms

TitleSummaryRegionLast ModifiedCategoryFile TypeFile SizeLinkhf:doc_tagshf:doc_categorieshf:file_type
Coordinated Bed Access Program Transfer Request Form 551B – EN

Completed by a Coordinated Bed Access Coordinator (HCCSS staff) for transfers in the rehab bed program

July 4, 2024pdf284 KBwaterloo-wellingtonformspdf
Form 031B – Hospice Palliative Care Services Request

Request for Hospice Palliative Care Services – Form 031B, Completed by a Primary Care Physician

July 24, 2024pdf1 MBwaterloo-wellingtonformspdf
Form 552 CBA Bed Vacancy Notification

Form 552, Notification of Rehabilitative Care, Palliative Care, Transitional Care or Residential Hospice Bed Vacancy

June 11, 2024pdf142 KBwaterloo-wellingtonformspdf
Formulaire de demande pour la divulgation de renseignements personnels

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

, , , , , , , , , , , , , , July 8, 2024pdf2 MBcentral central-east central-west champlain erie-st-clair global hamilton-niagara-haldimand-brant mississauga-halton north-east north-simcoe-muskoka north-west south-east south-west toronto-central waterloo-wellingtonformspdf
MAID (Medical Assistance in Dying) Fax Cover Sheet Form 068

Fax cover sheet that can be used to accompany MAID referral document

November 1, 2023pdf194 KBwaterloo-wellingtonformspdf
MAID (Medical Assistance in Dying) Referral Form 031A

Completed by a Primary Care Physician

November 1, 2023pdf151 KBwaterloo-wellingtonformspdf
Medical Orders – Parenteral Therapy – 525 – EN

To order care relating to parenteral therapy

July 4, 2024pdf296 KBwaterloo-wellingtonformspdf
Mental Health And Addictions Nursing Program (MHAN) Referral Form

Mental Health and Addictions Nursing Program Referral Form – Completed by a School Social Worker (SW) or Child/Youth Worker (CYW), Primary Care Physician, Psychiatrist, CAIP (GRH staff in the inpatient mental health program)

August 20, 2024pdf287 KBwaterloo-wellingtonformspdf
Negative Pressure Wound Therapy NPWT Order Form 046 – EN

Can be completed by a Primary Care Physician, Nurse Practitioner, NSWOC(Nurse specializing in wound, ostomy and continence care), or CNS (clinical Nurse specialist)

July 4, 2024pdf813 KBwaterloo-wellingtonformspdf
Negative Pressure Wound Therapy Referral Form

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

July 23, 2024pdf83 KBwaterloo-wellingtonformspdf
Palliative Care In-Patient Referral Form 279 – EN

FAX COMPLETED FORM TO Ontario Health atHome: 519-742-0635
How is Crisis defined?
A patient is considered to be “In Crisis” if:
1. Patient and/or caregiver safety is at risk and/or there is a risk that a significant health event and/or challenging end-of-life symptoms cannot be managed in their current setting
2. Patient at risk of requiring ED or acute care admission
3. Community resources have been exhausted and family/ caregivers are unable to cope with the patient’s care needs
4. There is a risk that the services required to meet the patient’s end-of-life care plan goals may not be available in their current setting
5. Patient at risk of not accessing their preferred place of death (considering recent trajectory of the PPS score).

July 31, 2024pdf2 MBwaterloo-wellingtonformspdf
Parenteral Nutrition (TPN) Referral Form 311A – EN

Completed by a Primary Care Physician or Registered Dietician

July 4, 2024pdf854 KBwaterloo-wellingtonformspdf
Rehab and Complex Continuing Care (CCC) Referral Form 550 – EN

Acute Care to Rehab & Complex Continuing Care (CCC) Referral

August 23, 2024, pdf310 KBwaterloo-wellingtoncba formspdf
Request for Release of Personal Health Information

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

, , , , , , , , , , , , , , August 15, 2024pdf2 MBcentral central-east central-west champlain erie-st-clair global hamilton-niagara-haldimand-brant mississauga-halton north-east north-simcoe-muskoka north-west south-east south-west toronto-central waterloo-wellingtonformspdf
Request for Services

Completed by Primary care Physician to request Home Care services. Patient/Families may also print this referral form to bring to an appointment for completion.

September 6, 2024pdf1 MBwaterloo-wellingtonformspdf
Retirement Home Service Information Form 150

Completed by Retirement Home(RH) or HCCSS staff to outline services that a patient is currently receiving or may require if moving to a Retirement Home setting

July 4, 2024pdf483 KBwaterloo-wellingtonformspdf
Swallowing Questionnaire Form 015 – EN

Completed by Retirement Home staff when requesting a Swallowing Assessment

July 4, 2024pdf465 KBwaterloo-wellingtonformspdf