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.

Reporting Forms

Reporting forms can be downloaded from the links below or requested from the Health Unit by emailing healthcareproviders@mlhu.on.ca or by calling 519-663-5317 ext. 3159.

Environmental Health

• Rabies Control Program - Duty to Report Form (PDF)

Immunization

• Adverse Effects Following Immunization (AEFI) (PDF)
• Anaphylaxis AEFI (PDF)
• Medical Exemption form (PDF)

Infectious Diseases

• Positive TB Skin Test / IGRA Report (PDF)
• Immediate Reporting Required
• Report as soon as possible, and by next working day

Substance Use

• Fentanyl Patch Return Sheet (PDF)

Order Forms

Order forms can be downloaded from the links below or requested from the Health Unit by emailing healthcareproviders@mlhu.on.ca or by calling 519-663-5317 ext. 3159.

Immunization

• Vaccine Order Form (PDF)
• School Vaccine Order Form for Gardasil and Menactra (PDF)
• Vaccine Return Form (PDF)

Prenatal

• Move for Two Order Form (PDF)

Infectious Diseases

• TB Medication Prescription and Order Form (PDF)
• PHO Lab Requisition

Consent Forms

Consent forms can be downloaded from the links below or requested from the Health Unit by emailing healthcareproviders@mlhu.on.ca or by calling 519-663-5317 ext. 3159.

Sexual Health

• Consent to Dispense Contraceptives (PDF)

Immunization

• Seasonal Influenza Immunization Consent Template (PDF)
• Seasonal Influenza Immunization Consent Template (DOC)