Let us meet your Telehomecare needs. Please complete the following form and we will respond within 2 business days.

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PLEASE READ BEFORE COMPLETING FORM:

Do not share any personal health information using this form. If you are a Telehomecare patient, please contact your Nurse by telephone.

By completing this form, you consent to OTN collecting, using and disclosing your personal information for the purpose of responding to your request and/or administering OTN's Telehomecare program(s) and/or service(s) you have requested. For questions on OTN's privacy practices please contact privacy@otn.ca.

First Name Last Name Organization Location (City/Province) Email Address Telephone Number

Please indicate who you are:

Telehomecare Nurse Telehomecare Admin A member of the public Health Care Professional Other

I am requesting:

General information (specify details below) Clinical assistance with a Telehomecare Practice Issue (specify details below) Educational materials not found on the website (specify details below) A Telehomecare demonstration (specify details below) A media request (specify details below) Other: Any Additional Comments?