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Middlesex-London Health Unit

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Forms for Healthcare Providers

The Middlesex-London Health Unit offers a variety of forms in an effort to simplify connections between the Health Unit and local healthcare providers. Please find the forms below.


Contact Us

To order forms from the Health Unit, please contact us.



Referral Forms

Child Development/Parenting/Prenatal Health/Post-partum
*Please save the PDF to your computer before filling out the form.

Intimate Partner Violence

  • iHEAL referral form (PDF)
    *Program to support women who have separated or are in the process of separating from an abusive partner.

Reporting Forms

Environmental Health


Infectious Diseases

Substance Use

Order Forms


All healthcare providers who order vaccines must use the online Public Health Ordering System (PHOS). To register for PHOS, please have your organization's primary contact complete the online registration form. Orders placed via fax or email are no longer being processed.

Infectious Diseases

Submission Forms

Consent Forms


Date of creation: September 23, 2016
Last modified on: January 9, 2023