Government of Ontario: Ministry of Health and Long-Term Care

Medical Certificate
Form 3

Homemakers and Nurses Services Act

To be completed by the attending physician where application is being made for the services of a registered nurse in the home of a person who is elderly, handicapped, ill or convalescent.

Name of applicant -last name, first name (please print)

Address (number, street name, city/town, Province, Postal code)

The applicant requires the services of a registered nurse on a visitation basis
in his/her home in order to (check):

enable him/her to remain at home

make possible his/her return home from the hospital or other institution named below

Name of hospital or institution

Address (number, street name, city/town, Province, Postal code)

a) Nursing procedures to be administered (check)

bed bath

catheterization

dressings

enemas

hypodermic injection

intravenous infusion

irrigation

other (specify)

Other specify

b) Visits recommended

daily

weekly , no of

monthly , no of

c) For a period of

days days

weeksweeks

monthsmonths

Physician's name -last name, first name (print)

Address (number, street name, city/town, Province, Postal code)

Date (yyyy/mm/dd)

Physician's signature

Homemakers and Nurses Services Act - Form 3 - Medical Certificate - July 1, 2007

2862-69E (07/08)

Disponible en Français

Government of Ontario: Ministry of Health and Long-Term Care

Medical Certificate Form 3

Medical Certificate
Form 3