Request for Information for Long-Term Care Placement
What is your name (e.g. First name, Last name)?
(Required)
As the requestor of information, please enter your own name, even if requesting on someone else’s behalf. This is required for us to contact you and respond to your request.
First name
This field is required
Last name
This field is required
What is the best phone number to reach you at?
(Required)
This is required for us to call you by phone. Email is not an option for Ontario Health atHome staff to contact you.
This field is required
Does the individual who may require long-term care have an Ontario postal code?
(Required)
This is required to help direct your request to the appropriate Ontario Health atHome local branch.
No
Yes
This field is required
Please enter the individual’s Ontario postal code for where they currently reside.
(Required)
This is required to direct your request to the individual's Ontario Health atHome local branch. Please remember to use the postal code of the individual you are requesting the information for.
This field is required
Validating Postal code...
Please select one of the following to be the primary region of interest. (If helpful, you can
Find your local branch here
)
(Required)
This is required to direct your request to the individual's Ontario Health atHome local branch. Please remember to use the postal code of the individual you are requesting the information for.
This is required to direct your request to the individual's Ontario Health atHome local branch.
Select one...
Central
Central East
Central West
Champlain
Erie St. Clair
Hamilton Niagara Haldimand Brant
North East
North Simcoe Muskoka
South East
South West
Toronto Central
Waterloo Wellington
Mississauga Halton
North West
This field is required
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