City of Fairbanks Community Paramedicine Referral Form
Are you an employee of Fairbanks Fire?
Yes
No
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Referrer's Information
Optional, but helpful
Referring Individual Name (Optional)
First Name
Last Name
Referring Individual Relationship to Client (Optional)
Please Select
Parent
Sibling
Friend
Aunt/Uncle
Niece/Nephew
Facility or Organization Staff
Facility/Organization Name
Referring Individual's Phone Number (Optional)
Please enter a valid phone number.
Client Information
Client Name
First Name
Last Name
Client Date of Birth (if known)
-
Month
-
Day
Year
Date
Client Phone Number (if available)
Please enter a valid phone number.
Client Housing Status
Unknown
Client has a permanent address
Client has a temporary address (including shelters)
Client is houseless.
Other
If Client is houseless or has temporary accommodations, please use this section to describe where we might find them. If possible, please also include time of day where they are most likely to be at this location(s):
Client Home Address (If known)
Street Address (include apartment number or description, if applicable)
City
Which of the following services will be needed for the patient?
Multiple Selection is available
Home Care
Evaluation & Treatment
Medication Education
Observation&Assessment of Condition
Patient/Family Education
Diabetic Care
Catheter Care
Nutritional Support
COPD Care
Congestive Heart Failure Care
Home Safety & Emergency Education
Ostomy Care
Wound Care
Other
Home Assessment
Gait/Transfer Training
Balance Training
Managing Home for Home Care
Exercise Program
Safe And Effective Use of Adaptive Equipment
Fall Prevention/Safety
Pain Management
Orthopedic Services
Neurological Rehab
Vestibular Rehab
Cardiovascular Rehab
Other
Life Management Assistance
Self-Care Management Training
Work Simplification Training
Task Segmentation Training
Energy Conservation Techniques
Other
Social Services Assistance
Community Resource Planning
Crisis Intervention
Long-Range Planning
Psychosocial Assessment
Medical Appointment Scheduling & Appointment Transportation
Other
Any other information you'd like to share?
Submit
Date
-
Month
-
Day
Year
Date
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FFD EMPLOYEE SECTION
THIS FORM
IS NOT HIPAA-COMPLIANT.
DO NOT INCLUDE PHI.
FFD REFERRING EMPLOYEE NAME
FFD REFERRING EMPLOYEE EMAIL
example@example.com
FFD Run Number (internal FFD use only)
FFD - Optional (but helpful): If this run was to a non-residential location (e.g. bus hut, etc), did you get any information from the client about where they usually reside?
OPTIONAL: PATIENT CARE RECOMMENDATIONS
If you think the patient could benefit from specific care and want to share your recommendations with the Community Paramedic, complete this section.
Home Care
Evaluation & Treatment
Medication Education
Observation&Assessment of Condition
Patient/Family Education
Diabetic Care
Catheter Care
Nutritional Support
COPD Care
Congestive Heart Failure Care
Home Safety & Emergency Education
Ostomy Care
Wound Care
Other
Home Assessment
Gait/Transfer Training
Balance Training
Managing Home for Home Care
Exercise Program
Safe And Effective Use of Adaptive Equipment
Fall Prevention/Safety
Pain Management
Orthopedic Services
Neurological Rehab
Vestibular Rehab
Cardiovascular Rehab
Other
Life Management Assistance
Self-Care Management Training
Work Simplification Training
Task Segmentation Training
Energy Conservation Techniques
Other
Social Services Assistance
Community Resource Planning
Crisis Intervention
Long-Range Planning
Psychosocial Assessment
Medical Appointment Scheduling & Appointment Transportation
Other
Any other information you'd like to share? (do not include PHI!!)
Print
Submit
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