Patient Referral for Community Paramedic Evaluation

Patient Referral for Community Paramedic Evaluation

Please complete this form to refer a patient to the Waller County Community Paramedic Program. Provide all required information to ensure timely processing.
Person or Organization Referring the Patient
Are you a Waller County EMS Employee?
ESO Incident Number
Date of Patient Contact

MonthDayYear
Date
Referring Organization
If applicable
Referring Contact Name
Referring Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Person Secure Email
Patient Information
Patient Name

First NameLast Name
Patients Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for Referral (select all that apply)
Describe Patients Relevant Medical History and Needs
Urgency Level
Should be Empty:

Person or Organization Referring the Patient