Pre-hospital Emergency Medical Services Referral

Please complete each section. Fax to the appropriate Health Care Professional(s).

Date: Gender: Male Female Surname First Initial Birth date Phone Number Age

Address Directions to home Place sticker here (if used). Copy of:  MAR Postal Code Personal Health Care Number Allergy/Intolerance Record Lives in:  house  apartment/condo  assisted living  personal care home  LTC  other ______Lives with:  alone/self  spouse  parent  child  caregiver  friend  family  other ______Care Coordinator: ______Referral to  EMS  HC  CPAS  Other______Contact phone number:______Title: ______Hazards /Precautions/ Special Considerations/Things to Note:

Pertinent Past Medical History  Diabetes  Cardiovascular Disease  Communicable Diseases ______ Asthma/ COPD  Rheumatic Diseases (RA/Lupus)  Neurological Degenerative Disease  Mental Illness  Osteoarthritis  Surgeries ______ Cancer  Chronic Musculoskeletal Condition  Past Injuries ______Reason for Referral /Goals for Treatment: Assistance to  manage OR  monitor medical conditions  New condition  Chronic condition Please describe:  Phlebotomy/Lab Services Request Details – frequency, time of day, etc.  IV Antibiotics (e.g.: TPR, BP 3x/week; BGM once weekly; BP q2d)  1st Dose  Subsequent Doses

 ECG  Vital Signs Monitoring  Bedside Glucose Monitoring  Discharge from hospital – Follow up  Medication Assist

TaskRequest  Fall Prevention Assessment  FROP  TUG  Environmental Survey  Hydration  Other

Contact Care Coordinator immediately if:

Comments:

Family notified of referral(s):  Yes  No. Family member name/relationship: Name of person who contacted family: Date:

Referral(s) date: ______Employee name: ______Signature: ______Service: ______Phone: ______Cellular: ______Fax: ______

September 2017 Page 1 of 4 Pre-hospital Emergency Medical Services Consent for Referral

Consent for the Collection, Use and Disclosure of Personal Health Information

The Health Region (SHR) and the Emergency Medical Services (EMS) are committed to respecting and ensuring that the privacy, security and confidentiality of personal health information collected, is consistent with The Health Information Protection Act (HIPA) of .

The goal of the EMS Referral Program is to improve overall health. Examples of services are but not limited to: accessing home care, community services, physicians, healthcare practitioners; and education on health promotion/injury prevention strategies, exercises to improve strength and balance, risk factors that contribute to falls and many other health related factors.

SHR and EMS are seeking permission to collect, use and disclose personal health information to physicians, nurse practitioners, family members, community partners (home care, nursing, therapies) and/or services to provide assistance in the prevention of a future concerns or to assist with current healthcare needs.

Consent is completely voluntary and should you not wish to consent your care will not be compromised.

Questions regarding the collection, use or disclosure of personal health information can be directed to the Pre-hospital Emergency Medical Services Clinical Nurse Educator at 1-306-231-4063. o Yes, I give EMS and SHR permission to collect, use and disclose my personal health information for the above noted purpose. o No, I do not give EMS and SHR permission to collect, use or disclose my personal health information for the above noted purpose. o Verbal consent obtained ○ Written consent obtained

______Patient Name (print) (Signature) (Date)

______Witness Name (print) (Signature) (Date)

September 2017 Page 2 of 4 Pre-hospital Emergency Medical Services

Fax

To: Phone Number: Service / Area: *see reverse side for listing of confidential fax numbers Fax Number: From: Phone Number: Service / Area: Fax Number:

Number of pages (including fax cover): Date: Re: EMS Client Referral

This client has consented to an EMS referral for an assessment or notification of a concern.

Please see the attached documents:  Referral form  EMS Consent for Referral  IV Antibiotics in community – please include the following documentation for a CPAS referral  HITP Referral Form  Physician’s Order  Contact information for the client  Contact information for consulting EMS service

 Other:

We kindly request you respond to this fax to ensure this referral has reached the recommended healthcare professional.

Notice of confidentiality: This transmission is intended only for the recipients(s) listed above and may contain information that is time sensitive or confidential. If you are not the intended recipient, any use, disclosure, copying or communication of the contents of this transmission is prohibited. If you have received this fax in error, please notify the sender immediately and destroy this copy.

September 2017 Page 3 of 4 Confidential Fax Numbers:

Emergency Medical Services

Ground Ambulance Services Humboldt & District Ambulance 306-682-2709 Lanigan & District Ambulance 306-365-2190 or 306-365-1201 MD Ambulance Care Ltd. (Saskatoon) 306-664-2112 or 306-242-2686 Midway Ambulance Care Ltd. (Wynyard) 306-554-2924 Quill Plains Ambulance Care Ltd. (Watson, SK) 306-287-4212 & District Ambulance 306-232-5036 Shamrock Ambulance Care Inc. (Wadena, SK) 306-554-2924 Strasbourg Emergency Medical Services 306-725-2057

Wakaw & District Emergency Medical Services 306-233-4308 (Prior notification of fax is required, service must be expecting the fax) Watrous & District Ambulance (SHR) 306-946-2369

Saskatoon Health Region

CPAS 306-655-4343 Mental Health & Addiction Services – Rural Phone Numbers only – client to contact Lanigan & Area 306-365-3400 Humboldt & Area 306-682-5333 Rosthern & Area 306-232-6001 Wakaw & Area 302-233-4020 Mental Health & Addiction Services – Urban 306-655-7777 Pharmacy Humboldt District Health Centre (Rural Areas) 306-682-4461 Saskatoon City Hospital - 306-655-7636 Home IV Therapy Pharmacy (HITP) (Urban Area) Public Health Immunization/Disease Control 306-655-4723 (Attention Immunization Dept. Office) Seniors First Program 306-655-4400 Home Care – Rural East – Wadena, Wynyard 306-338-2297 Humboldt 306-682-4417 North – Wakaw, Cudworth, Rosthern Wakaw 306-233-4653; Rosthern 306-232-5218 South – Lanigan, Watson, Strasbourg, Nokomis 306-365-2208 Home Care Urban East: 306-655-4450 West: 306-655-4449 Idylwyld: 306-655-4400

September 2017 Page 4 of 4