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
YesNo
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
Post-hospital dischargeFrequent EMS utilizationChronic condition managementMedication reconciliationMental health follow-upSocial needs support
Describe Patients Relevant Medical History and Needs
Routine (≤7 days)Priority (≤72 hours)
Should be Empty:

Person or Organization Referring the Patient