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.

Referral Forms

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

• Healthy Babies Healthy Children Screen (PDF)
• Nurse-Family Partnership ® (NFP) (PDF)
• Prenatal Immigrant Program (PDF)

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

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

Immunization

• Adverse Effects Following Immunization (AEFI) (PDF) Learn more about AEFIs and how to report →
• Anaphylaxis AEFI (PDF)
• Medical Exemption form (PDF)

Infectious Diseases

• COVID-19 Reportable Disease Notification Form
• Positive TB Skin Test / IGRA Report (available in EMR format, search Middlesex-London Health Unit) 

• Reportable Disease Notification Form (PDF) (available in EMR format, search Middlesex-London Health Unit)
• Veterinary Reportable Disease Form (DOC)

Substance Use

• Fentanyl Patch Return Sheet (PDF)

Order Forms

Immunization

• Public Funded Influenza Vaccine Order Form (PDF)
• Publicly Funded Routine Vaccine and TB Order Form (PDF)
• Publicly Funded High Risk Vaccine Order Form (PDF)
• Publicly Funded School Immunization Order Form (PDF)
• Vaccine Return Form (PDF)

Infectious Diseases

• TB Medication Prescription and Order Form (DOC) (available in EMR format, search Middlesex-London Health Unit)
• PHO Lab Requisition

Submission Forms

• Tick Submission Form (PDF)

Consent Forms

Immunization

• 2021-2022 Influenza Vaccine Consent Form (PDF)