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Service Information

Service:

Community Paramedicine Program
Organization: District of Nipissing Community Paramedicine Program
Description:

Non emergency response to complex health care situations with the goal of preventing 911 calls and E/R presentation
Supporting patients to remain safely in their home including Geriatric Assessments and other in home care
No family doctor required

Referral Options:

Services Requested:*

12-lead ECG

Blood Chemistry/Blood Draw

Cognitive Screening

Catheter Care

Disease Education/Information

General Safety Check - Routine

General Safety Check - Urgent

Geriatric Assessment

LTCH Waitlist Support

Mobility Assessment

Medication Review/Compliance

Physical Assessment/Vitals

Palliative Support/Pain Management

Post Hospital Discharge Check

Respiratory Disease Screening

Respiratory Therapy Assessment

Remote Monitoring

Safety Scan

Specialized Medication

Urinalysis

Vaccine-Covid

Vaccine-Influenza

Vaccine-Other

Virtual Appointment Assistance

Wellness Check/Vitals

Wound Care/Treatment

Other

Required: choose at least one option

If "other" selected, please specify:

Applicable History:*

Abusive Living Arrangement

Acute Decline

ALC Risk

Awaiting LTC

Cognitive Impairment

DNR in Place

Food Insecurity

Health Care Avoidance

Issues with Self Care (dressing/bathing)

Lives Alone

LTC Crisis

Multiple Comorbidities

Medication Non-Compliance

No Formal Care Arranged

No Family Support

Recent 911/ER Admissions

Recent Fall(s)

Remote Location

Safety Conditions of Residence/Home

Substance Abuse

Services Waitlisted

Self Harm

Uncared for Pets/Animals

Other

Required: choose at least one option

If "other" selected, please specify:

Agencies Involved:

Behavioural Support Ontario

Community Paramedic

Community Support Services

CMHA

Geriatric Emergency Management

Geriatric Clinic

OHAH Rapid Response Nurse

OHAH Nurse Practitioner

OHAH Nursing

OHAH Personal Support

Seniors Mental Health

Veterans Affairs

Other

If "other", selected, please specify:

Patient Information

Patient Name:

First name*

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Family/Last Name*

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Email Address:

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone*

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Address:

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Street # & Street Name*

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City*

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Province/State*

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Postal/Zip Code*

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Gender:

Male

Female

Undisclosed/Other

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Date of Birth:*

Day

Month

Year

Age: ( corrected)

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Patient Health Card Number:

Patient Health Card Number

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Version Code

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Marital Status:

Single

Married

Common Law

Separated

Divorced

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Family Doctor:

Family Doctor Name

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Family Doctor Phone #

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Caregiver / Emergency Contact

Relationship to Patient:

Spouse

Son/Daughter

Sibling

Parent

Mother

Father

Friend

Legal Guardian

Other

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Caregiver / Emergency Contact Name:

First name

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Family/Last Name

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Caregiver / Emergency Contact Info:

Primary Phone

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Secondary Phone

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Health Information

Referral Urgency:*

Routine/Elective

Semi-Urgent

Urgent

Other

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Related Hospital Visit:

Recent Discharge

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Admission Date (yyyy-mm-dd)

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Discharge Date (yyyy-mm-dd)

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Relevant Medical History:*

Please include the reason for referral, immediate goal and relevant medical history/services

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Additional Information

Referring Party Name:*

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Referring Party Title & Workplace:*

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Referring Party Phone #:*

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Referring Party Email:

Documentation:

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Are you sending any additional documentation separately by a method other than online through Caredove (e.g, via fax)?

Yes

Consent

Has the patient consented to this referral?

Yes

Consent obtained by:

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Summary

Reference #: -

Registrant:
Organization:

District of Nipissing Community Paramedicine Program

Service:

Community Paramedicine Program

Inquiry Phone:

1 (705) 474-5750

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