Patient Referral Form
FOR PROFESSIONAL REFERRALS ONLY
Referring Professional Information
Please complete the following information about the professional/provider making the referral
Name of Referring Clinic/Organization
*
Organization Name
Referring Professional's Name
*
First Name
Last Name
Have you referred a patient to EFMN before using this form?
*
Yes, I have
No, this is my first time
Unsure
Professional's Role / Title
*
Professional's Email
*
example@example.com
Professional's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Patient Information
Please complete the below information about the Patient
Patient Name
*
First Name
Last Name
Patient Zip code (Home)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Is patient over the age of 18?
Yes
No
Seizure Types (check all that apply)
*
Generalized Tonic Clonic
Absence
Focal Impaired Awareness
Focal non impaired awareness
Myoclonic
Atonic
Unknown
Other
Patient's Preferred Language
*
Does the patient have a Primary Caregiver and/or is patient a minor?
*
Yes
No
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Caregiver Information
Caregiver Name
*
First Name
Last Name
Caregiver's relationship to person living with epilepsy
*
Child Has Epilepsy
Parent Has Epilepsy
Spouse or Partner Has Epilepsy
Other
Does caregiver live at the same address as the patient?
*
Yes
No
Caregiver's Zip Code (please provide if caregiver and patient do not live at the same address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver's Email
example@example.com
Caregiver's Preferred Language
*
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Please provide a brief overview of the client's key needs and situation.
Authorization:
*
By clicking this box, I confirm I have discussed this referral with the patient and/or caregiver and obtained their consent to be a part of the Care Coordination Program with the Epilepsy Foundation of Minnesota. The patient and/or caregiver has consented to being contacted by the Epilepsy Foundation of Minnesota.
Submit
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