Caredove

Request to Become a Referrer

Name:*

Email:*

Organization:*

Job Title:*

Work Phone:*

Message:

Cancel

Service Information
Form
Finish

Service Information

Service:

Community Paramedicine Program - Healthcare Providers
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
No family doctor required

Referral Options:

Requested Program:*

Community Paramedicine Program

Geriatric Community Outreach Program

Required: choose at least one option

Services Requested:*

General Safety Check - Routine

General Safety Check - Urgent

Wellness Check/Vitals

12-lead ECG

Cognitive Screening

Physical Assessment

OTN Appointment

LTCH Waitlist Support

Remote Monitoring

Safety Scan

Geriatric Assessment

Disease Education/Information

Mobility Assessment

Urinalysis

Wound Care/Treatment

Blood Chemistry

Covid Vaccine/Swabs

Influenza Vaccine/Swabs

Post Hospital Discharge Check

Catheter Care Initiation

Specialized Medication

Medication Review Compliance

Other

Required: choose at least one option

If "other" selected, please specify:

Applicable History:*

Remote Location

Multiple Comorbidities

Acute Decline

ALC Risk

Awaiting LTC

LTC Crisis

DNR in Place

Recent 911/ER Admissions

Recent Fall

Cognitive Impairement

Substance Abuse

Health Care Avoidance

No Formal Care Arranged

Medication Non-Compliance

Food Insecurity

Lives Alone

Abusive Living Arrangement

Safety Conditions of Residence/Home

No Family Support

Self Harm

Issues with Self Care (dressing/bathing)

Uncared for Animals

Other

Required: choose at least one option

If "other" selected, please specify:

Agencies Involved:

Community Paramedic

Geriatric Emergency Management

Seniors Mental Health

CMHA

Community Support Services

Veterans Affairs

NESGC

Behavioural Support Ontario

HCCSS High Intensity CC

HCCSS Rapid Response Nurse

HCCSS Nurse Pratitioner

HCCSS Nursing

HCCSS Personal Support

Other

If "other", selected, please specify:

Patient Information

Patient Name:

First name*

This field is required

Family/Last Name*

This field is required

Email Address:

Email (Confirmation and reminder emails will be sent here)

This field is required

Phone:

Primary Phone*

This field is required

Address:

Unit/Suite #

This field is required

Street # & Street Name*

This field is required

City*

This field is required

Province/State*

This field is required

Postal/Zip Code*

This field is required

Select location on a map

Gender:

Male

Female

Undisclosed/Other

This field is required

Date of Birth:*

Day

Month

Year

Age: ( corrected)

This field is required

Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Patient Health Card Number:

Patient Health Card Number

This field is required

Version Code

This field is required

Marital Status:

Single

Married

Common Law

Separated

Divorced

Widowed

This field is required

Family Doctor:

Family Doctor Name

This field is required

Family Doctor Phone #

This field is required

Caregiver / Emergency Contact

Relationship to Patient:

Spouse

Son/Daughter

Sibling

Parent

Mother

Father

Friend

Legal Guardian

Other

This field is required

Caregiver / Emergency Contact Name:

First name

This field is required

Family/Last Name

This field is required

Caregiver / Emergency Contact Info:

Primary Phone

This field is required

Secondary Phone

This field is required

Health Information

Referral Urgency:*

Routine/Elective

Semi-Urgent

Urgent

Other

This field is required

Related Hospital Visit:

Recent Discharge

This field is required

Admission Date (yyyy-mm-dd)

This field is required

Discharge Date (yyyy-mm-dd)

This field is required

Relevant Medical History:*

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

This field is required

Additional Information

Referring Party Name:*

This field is required

Referring Party Title & Workplace:*

This field is required

Referring Party Phone #:*

This field is required

Referring Party Email:

Documentation:

Please ensure you attach all relevant requisitions to this referral.

Add files

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:

This must be to continue

This field is required

clear consent values

By clicking "Finish", you agree to send this personal information to District of Nipissing Community Paramedicine Program online.

You agree to these Terms and Conditions and Privacy Policy, which govern how your personal information is kept safe.

Notifications:

Send confirmation, change & reminder messages to < name > < email >

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to District of Nipissing Community Paramedicine Program, but you have some steps left:

Save Confirmation
Print a handout to give to the registrant.

A confirmation message will be sent to - -

Summary

Reference #: -

Registrant:
Organization:

District of Nipissing Community Paramedicine Program

Service:

Community Paramedicine Program - Healthcare Providers

Inquiry Phone:

1 (705) 474-5750

Tip: Referrals can be viewed by navigating to referrals in the top menu

Cancel

Appointment Service area map

Red area: Service area for this appointment

Grey area: Service delivery area

Home Address

Trip Map

Driving Distance: 0km

Select Form Name

Name:*

This field is required

Add Form Name

Name:*

This field is required

Select Location on a Map

You need Javascript enabled to use Caredove. Please visit diagnostics page for more information. #noscript-warning { font-family: sans-serif; position: fixed; top: 0; left: 0; width: 100%; z-index: 101; text-align: center; font-weight: bold; font-size: 120%; color: #FFF; background-color: #AE0000; padding: 5px 0 5px 0; }