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

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.

• 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

• 2022-2023 Influenza Vaccine Consent Form (PDF)