Samaritan House Patient Referral

Samaritan House Patient Referral

(Please complete all information below)
Patient Name:*

First NameLast Name
Patient Middle Name:*
Patient Birthdate:*

MonthDayYear
Social Security #:*
Diagnosis / Illness:*
What is the patient's weight?*
Recuperative Care Need(s):*
How many days of respite/recuperative care is requested by medical provider?*
Is the guest appropriate for communal living?*
Has the guest tested positive for Hepatitis or HIV?*
Are they currently on medication to treat HIV or Hepatitis?*
Has the patient been diagnosed with a serious mental health illness? (ie: schizophrenia, bipolar disorder, etc.):*

YesNo
If "Yes" to above mental health, what is the patients diagnosed illness?
If "Yes" to above mental health, has patient been on mental health meds for at least 21 days continuous?

YesNo
Can patient manage their own daily care (including medication management and/or dressing changes?:*

YesNo
Does the guest require home health care?*
Does the patient have any COVID-19 symptoms?*

YesNo
(11) Has the patient been vaccinated for Covid-19?:*

YesNo
(12) Has the patient tested "Negative" for Covid-19 and/or other variants in the past 72 hours?:*

YesNoUnknownWaiting for results of test
Please Note:

If the patient has not received the Covid-19 vaccination, they may be required to wear a mask while interacting with others at Samaritan House until we can get him/her vaccinated. If the patient refuses to get the Covid-19 vaccination, and/or our mask policy, he/she may not be accepted into Samaritan House.
Referred By:*

First NameLast Name
Referring Facility / Agency:*

Atrium MAINAtrium MERCYAtrium UNIVERSITYAtrium PINEVILLELevine Cancer (LCI)Novant MAINOther
If "Other" from above, please list facility name / agency name here:
Referral Contact #:*
Please enter a valid phone number.
Referring Email:*
This should be completed by the referring Social Worker, Nurse, Agency Rep., etc.
Referral Date:*

MonthDayYear
Date
Should be Empty: