121 Forms found for example-of-a-medical-license-number

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  • on00511
    Referral for Tertiary Medical Consultation Service

    The form is used to refer a child/youth to tertiary medical consultation services at CPRI. This is a one-time developmental behavioural consultation with a CPRI paediatrician or a psychiatrist. It can also include diagnostic opinion/interdisciplinary ASD diagnostic assessment. Referrals will only be accepted from a medical specialist (e.g. paediatrician, psychiatrist, neurologist, geneticist). All CPRI recommendations are provided to the referring specialist.

  • 014-2203-64
    Toronto Clients Requisition for Biological Supplies (for use in M postal code areas only)

    Used by Toronto Clients to order Biological Supplies from Ontario Government Pharmaceutical and Medical Supply Service.

  • 014-0951-84
    Out-of-Province/Out-of-Country Claim Submission

    Form used so patient can submit out of country medical receipts

  • 4969-47
    Diabetes Education Checklist

    The MedsCheck for Diabetes includes an Annual review that involves using the pharmacist's worksheet and providing the patient with a MedsCheck Personal Medication Record; as well as using a Diabetes Education Checklist and providing the patient with a Diabetes Education Patient Take-Home Summary.

  • 4970-47
    Diabetes Education Patient Take Home Summary

    The MedsCheck for Diabetes includes an Annual review that involves using the pharmacist's worksheet and providing the patient with a MedsCheck Personal Medication Record; as well as using a Diabetes Education Checklist and providing the patient with a Diabetes Education Patient Take-Home Summary.

  • on00675
    Surety Bond Template

    This is a surety bond template, which is to be used in the context of temporary help agency and recruiter licensing under the Employment Standards Act, 2000.

  • 2189
    Drinking Water Information - O. Reg. 243/07

    This form is used for registering a facility, updating or revoking an existing registration, the identification of a licensed laboratory or to provide notice of reduce lead sampling.

  • 023-sr-ld-054
    Application for Ontario Driver's Licence

  • 010-3042
    Statement of Conscience or Religious Belief

    To allow individuals to apply for religious/conscience exemptions for immunizations

  • 018-0488
    Application Form for Cage Aquaculture Facilities in Ontario

    The purpose of this Application Form is to provide MNRF with the necessary information to process and review a request for a new (Type A), revised (Type B) or renewed (Type C) license for Cage Aquaculture Facilities.

  • 011-0027
    Application for Ontario's Home Energy Audit Grant (Program)

    Application Form for entry into the Ontario Home Energy Audit Program for Corporate Owned Residential Properties. Homeowners are required to complete this form with a licensed Energy Advisor during their home energy audit to be eligible for an audit grant. For more information, visit www.ontario.ca/homeneergy

  • on00334
    Clinician Aid D-1 - Waiver of Final Consent

    The use of this aid is voluntary. It is being provided to assist you in maintaining records for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting a Waiver of Final Consent. The Waiver of Final Consent is ONLY applicable for individuals whose natural death is reasonably foreseeable (RFND).

  • 014-4579-64
    Notice to Operate or Reopen a Small Drinking Water System

    The Small Drinking Water System Identification form is to be used by owners of small drinking water systems to notify in writing the medical officer of health in the health unit where their system is located before supplying drinking water to users of the system following construction or alteration of the small drinking water system or following a shut-down of the system that lasts longer than seven days.

  • 011-0022
    Application for Ontario's Home Energy Audit Grant (Program)

    Application Form for entry into the Ontario Home Energy Audit Program. Homeowners are required to complete this form with a licensed Energy Advisor during their home energy audit to be eligible for an audit grant. Please visit the program website at www.ontario.ca/homeenergy for more information.

  • 0327-88
    Application for Northern Health Travel Grant

    Used to apply for financial travel assistance by Northern Ontario residents who must travel long distances to access medical specialist services.

  • 014-4897-64
    Statement of Conscience or Religious Belief – Immunization of School Pupils Act

    A parent must complete a Statement of Conscience or Religious Belief and have it witnessed by a commissioner for taking affidavits if they wish to obtain a non-medical exemption for their child from vaccine requirements under the Immunization of School Pupils Act.

  • on00384
    Clinician Aid D-2 – Advance Consent – Self-Administration

    The use of this aid is voluntary. It is being provided to assist you in maintaining records for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting Advance Consent for MAID Self-Administration.

  • 014-3296-64
    Non-Reusable Vaccine (spoiled or expired) Return Record - Toronto Clients

    Used by Toronto clients to return non-reusable vaccines (spoiled or expired) to the Ontario Government Pharmaceutical and Medical Supply Service

  • 4611-45
    Paramedic Labour Mobility Application

    Application and Verification forms for the Ministry of Health (MOH) Paramedic Labour Mobility Equivalency for Paramedics who hold a valid license or certification in good standing from other Canadian provinces or territories and wish to obtain equivalency in Ontario for their paramedic qualification.

  • on00559
    Telescopic Lens Renewal

    This form is used exclusively for the Ministry of Transportation’s Telescopic Lens Program to obtain regular updates to ensure participants continue to meet licensing requirements.