Community Paramedic Referral - Lambton Public Health

County of Lambton Community Paramedic Referral

If you have a time sensitive request please call 519-328-1179 or email community.paramedic@county-lambton.on.ca.

Check off service needed(Required)

Health Promotion & Education

Hospital Transition

Community Paramedic Home Visiting Program

Other

If other, please specify:(Required)

Referrer Information

The information contained in this referral form is confidential and is intended only for use of the individual or entity to whom it is addressed.

Referring Health Care Agency:(Required)

Referring Case Leader:

Case Leader Phone #:

Email:(Required)

This email will be used to send a confirmation email

Submission Date:(Required)

Primary Care Provider Information

Primary Care Provider Information:

Client’s Primary Care Physician’s MOST Direct Contact #:

Client Information

Name (First and Last)(Required)

Address(Required)

Street Address City Province Postal Code

Client Phone (Home or Cell):(Required)

Health Card #:(Required)

Alternate Contact (If applicable)

First Last

Alternate Contact Phone #

Relationship to Client

Clients Medical History

Client’s Priority/ Working Diagnosis (If none, please state "Not Applicable")(Required)

Client’s Conditions (list all conditions) (If none, please state "Not Applicable")(Required)

Client’s Medication Profile (If none, please state "Not Applicable")(Required)

Client’s Allergies (If none, please state "Not Applicable")(Required)

Does this Client have an Action Plan in Place?

Yes (if yes attach plan)

Upload Action Plan

Drop files here or

Max. file size: 64 MB.

Please outline any Special Procedures required for the Client Please outline the frequency of visits for this Client

Please outline any priority assessments to complete during the Client Visit

The information in this form is being collected, used, and disclosed subject to the Personal Health Information Protection Act, 2004 (Ontario) and the Ambulance Act (Ontario). Personal information contained on this form is collected to ensure efficient and appropriate care. A client’s primary care provider may be contacted and consulted as a part of the circle of care. Any questions regarding the collection, use and disclosure of this information may be directed to Lambton Public Health at 519-383-8331 or toll free 1-800-667-1839.