Yancey County Community Paramedic Program

Patient Referral Form

For healthcare providers, agencies, and community partners. Please contact the patient and let them know about this referral so they will be expecting our call. If the visit reveals anything urgent, the referring provider will be contacted; otherwise a summary letter will be faxed to the requesting provider's office.

Questions? Call the Community Paramedic at 828-682-1829.

* Required field

Referring Agency or Individual

Name *

Agency / Practice

Phone *

Fax (for the summary letter)

Patient Information

Patient name *

Date of birth

Age (if DOB unknown)

Address *

Patient phone *

Sex

PCP name

PCP phone

Is the patient aware of this referral? *

Yes No

Any safety concerns for the paramedic? *

Yes No

Brief medical history and allergies

How can we help? Describe any safety concerns.

Discharge note or recent chart notes (PDF, image, or Word; up to 10 MB)

Reasons for Referral (check all that apply)

If other, please describe

Typical interactions include

Vital signs / physical assessment
Blood glucose assessment
Home safety and CO/smoke detector checks
Medication compliance / understanding
Fall risk assessment
Hypertension follow-up
Assessment of social connections and caregiver support
Assessment of need for additional home resources

Other available interventions

12-lead / advanced cardiac assessment
Welfare checks
72-hour opioid misuse follow-up
Education / plan of care review
Lab work samples

Referral received

Typical interactions include

Other available interventions