Critical / Special Needs Patient Registration
For anyone in WCESD #3 service area with special medical needs
Name
*
First Name
Last Name
Email
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your emergency contact's name
*
First Name
Last Name
Your emergency contact's phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are the medical necessity concerns? Select all that apply
Oxygen Dependent
On a ventilator (ventilator dependent)
Bedbound (normally unable to get out of bed)
Wheelchair Bound
On a concentrator
Life Vest Patient
LVAD
Other
List any other health concerns you want us to be aware of in a weather related or disaster type emergency? (For example you are on an oxygen concentrator, ventilator dependent, or some other medical device that requires electricity to operate.)
*
For patients that are required to use medical equipment around the clock, is there a generator onsite or spare battery backups in the event there is a power outage?
Yes
No
For oxygen dependent patients or patient on concentrators, do you have spare oxygen tanks? Please provide details here with the quantities.
Any information provided will not be shared, sold, or redistributed. It will be kept secure, following all HIPAA requirements to protect patient information.
Call 830-581-0380 with any questions.
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