Community Paramedic Referral County of Lambton Community Paramedic ReferralIf you have a time sensitive request please call 519-328-1179 or email firstname.lastname@example.org.Check off service needed(Required) Health Promotion & Education Hospital Transition Remote Monitoring Other If other, please specify:(Required) Referrer InformationThe 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 emailSubmission Date:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Care InformationPrimary Care Information: Client’s Primary Care Physician’s MOST Direct Contact #:Client InformationName (First and Last)(Required) Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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 HistoryClient’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) No Upload Action Plan Drop files here or Select files Max. file size: 8 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.