EMS Patient Follow-Up
EMS Liaison Perry McAlister will be on PTO 3/28-4/5 and will reply to JOT form requests as soon as possible upon her return. Fill out this form to receive feedback/patient update on your patient via phone call (540-536-5587) by the Valley Health EMS Liaison.
Back
Next
By checking this box, I attest that I provided direct patient care for the patient I am requesting an update on.
I attest
I acknowledge that HIPAA Identifiers can NOT be put on this form. HIPAA Identifiers include name, date of birth, address, MRN, and CSN.
*
I acknowledge
Back
Next
EMS Provider Name (DO NOT SHARE PATIENT NAME)
*
First Name
Last Name
Email
example@example.com
Phone Number (you will be contacted at this number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Transport Destination
*
Please Select
Winchester
Warren
Shenandoah
Page
Other
If other:
Date of EMS Transport
*
-
Month
-
Day
Year
Date
Estimated Time of Transfer of Care to Hospital
*
Hour Minutes
Back
Next
Transporting Agency
*
Frederick County
City of Winchester
Clarke County
Warren County
Shenandoah County
Page County
Other
Other (if applicable)
Transporting Unit Number
*
Helicopter/Other Unit/Other Agency (if applicable)
Back
Next
Patient Type
*
Please Select
Medical
Trauma
STEMI
Stroke
Pediatric
OB
Other/unknown
Back
Next
Specific feedback requested, if applicable: **do NOT share any HIPAA-related information, such as patient name, date of birth, address, or MRN number. You may however include patient's age, gender and chief complaint.
Back
Next
EMS Liaison Perry McAlister will be on PTO 3/28-4/5 and will reply to JOT form requests as soon as possible upon her return.
If you do not receive follow-up within 3 business days of your request, please contact Perry at 540-536-5587 or pmcalist@valleyhealthlink.com to ensure your form was submitted and received.
Submit
Should be Empty: