This referral is for

 House Calls primary care
 House Calls palliative care
 I'm not sure which service is more appropriate for this patient.

 

Referrer Information

Name of referrer*
Position / Title
Place of employment*
Phone number*

 

Patient Information

First Name*
Middle Name*
Last Name*
Date of Birth*
Is the family aware that a referral is being made to House Calls?*
   Yes
 No
Who should we call to schedule the visit?
Name*
Relationship
Phone number*
Alternate phone or email
Patient current location
Patient home address
Patient phone number
Is the patient in the clinic/hospital at the time the referral is being called in?
   Yes
 No
SSN
Insurance
Military service*  Yes
 No
 Unknown
Is patient able to make own decisions and sign own consent?
   Yes
 No
Referring physician
Attending physician
Is attending provider aware of this referral?                                                  
                                           Yes
 No

Is it a challenge for this patient to leave home for medical visits? Would they benefit from a home-based medical program?*

If yes, why? 

 

Is there a specific medical issue which requires aggressive medical management?*

  
If yes, what is that issue?


You may attach the face sheet or other medical information: