Eastside Use Only Form Generator - Please do not edit
* must provide value
Disclaimer
Submit Password
Submit
Full Name Nombre completo: * must provide value
Date of Birth Fecha de nacimiento: * must provide value
Today M-D-Y
Reliable Phone Number Número de teléfono fiable: * must provide value
Patient's Email Address Correo electrónico del paciente: * must provide value
Have you been seen at Equal Access Clinic before? ¿Ud. ha sido atendido en la clínica de Equal Access anteriormente? * must provide value
Yes, at a primary care clinic Sí, en una clínica general
Yes, at the physical therapy clinic Sí, en la clínica de fisioterapia
No
Yes, at a primary care clinic Sí, en una clínica general
Yes, at the physical therapy clinic Sí, en la clínica de fisioterapia
No
At which clinic site are you regularly seen? * must provide value
Anthem Clinic (Monday)
Eastside Clinic (Tuesday)
Bartley Clinic (Wednesday)
Main Street Clinic (Thursday)
Physical Therapy Clinic (Thursday)
Anthem Clinic (Monday)
Eastside Clinic (Tuesday)
Bartley Clinic (Wednesday)
Main Street Clinic (Thursday)
Physical Therapy Clinic (Thursday)
Reason for Visit Razón por la visita Example: medication refill, gender affirming therapy, follow up on labs, physical therapy, etc.Ejemplos: Resurtido de medicamento, terapia de afirmación de género, darle seguimiento a resultados de laboratorio, fisioterapia, etc.
* must provide value
Are you experiencing any new symptoms since you were last seen? ¿Ha sufrido algún síntoma nuevo desde la última visita? * must provide value
Yes
No
What is your preferred language? ¿Cuál es su idioma predilecto?
* must provide value
English Inglés
Spanish Español
Other Otro
English Inglés
Spanish Español
Other Otro
Please enter your preferred language. * must provide value
Please indicate all your availability for a phone call. Please include as many time slots as possible. * must provide value
Monday Morning (8am-12pm)
Monday Afternoon (12pm-4pm)
Monday Evening (4pm-8pm)
Tuesday Morning (8am-12pm)
Tuesday Afternoon (12pm-4pm)
Tuesday Evening (4pm-8pm)
Wednesday Morning (8am-12pm)
Wednesday Afternoon (12pm-4pm)
Wednesday Evening (4pm-8pm)
Thursday Morning (8am-12pm)
Thursday Afternoon (12pm-4pm)
Thursday Evening (4pm-8pm)
Friday Morning (8am-12pm)
Friday Afternoon (12pm-4pm)
Friday Evening (4pm-8pm)
Monday Morning (8am-12pm)
Monday Afternoon (12pm-4pm)
Monday Evening (4pm-8pm)
Tuesday Morning (8am-12pm)
Tuesday Afternoon (12pm-4pm)
Tuesday Evening (4pm-8pm)
Wednesday Morning (8am-12pm)
Wednesday Afternoon (12pm-4pm)
Wednesday Evening (4pm-8pm)
Thursday Morning (8am-12pm)
Thursday Afternoon (12pm-4pm)
Thursday Evening (4pm-8pm)
Friday Morning (8am-12pm)
Friday Afternoon (12pm-4pm)
Friday Evening (4pm-8pm)
Indique todo su disponibilidad para una llamada telefónica. Por favor, incluya todos los tiempos posibles. * must provide value
Lunes - Mañana (8 AM - 12 PM)
Lunes - Tarde (12 PM - 4 PM)
Lunes - Noche (4 PM - 8 PM)
Martes - Mañana (8 AM - 12 PM)
Martes - Tarde (12 PM - 4 PM)
Martes - Noche (4 PM - 8 PM)
Miércoles - Mañana (8 AM - 12 PM)
Miércoles - Tarde (12 PM - 4 PM)
Miércoles - Noche (4 PM - 8 PM)
Jueves - Mañana (8 AM - 12 PM)
Jueves - Tarde (12 PM - 4 PM)
Jueves - Noche (4 PM - 8 PM)
Viernes - Mañana (8 AM - 12 PM)
Viernes - Tarde (12 PM - 4 PM)
Viernes - Noche (4 PM - 8 PM)
Lunes - Mañana (8 AM - 12 PM)
Lunes - Tarde (12 PM - 4 PM)
Lunes - Noche (4 PM - 8 PM)
Martes - Mañana (8 AM - 12 PM)
Martes - Tarde (12 PM - 4 PM)
Martes - Noche (4 PM - 8 PM)
Miércoles - Mañana (8 AM - 12 PM)
Miércoles - Tarde (12 PM - 4 PM)
Miércoles - Noche (4 PM - 8 PM)
Jueves - Mañana (8 AM - 12 PM)
Jueves - Tarde (12 PM - 4 PM)
Jueves - Noche (4 PM - 8 PM)
Viernes - Mañana (8 AM - 12 PM)
Viernes - Tarde (12 PM - 4 PM)
Viernes - Noche (4 PM - 8 PM)
I would like to receive updates about the Equal Access Clinic Network (EACN) by text message at my phone number above.
Me gustaría recibir noticias sobre la red de clínicas de Equal Access (EACN) por mensaje de texto al número apuntado arriba. Please check "yes" if you are interested in being contacted by text message in the future. Messages will be limited to twice per week at most. Your contact information will not be shared, this choice will not impact the clinical care we provide, and you may opt out at any time.
Favor de marcar "sí" si le interesa estar contactado/a por mensajes de texto en el futuro. Mensajes estarán limitados a dos veces por semana al máximo. Su información de contacto no será compartido, esta decisión no afectará el cuidado medico que proveemos, y Ud. puede optar por no participar en cualquier momento. * must provide value
Yes
No
Thank you! We look forward to speaking with you soon. Please be on the lookout from a call from our office: (352) 273 - 9425
Try your best to be available during the indicated available times.
Gracias! Esperamos hablar con Ud. pronto. Favor de estar pendiente de una llamada de nuestra oficina: (352) 273-9425.
Haga lo posible para estar disponible durante los horarios indicados.
Nombre completo: Full Name * must provide value
Fecha de nacimiento: Date of Birth * must provide value
Today M-D-Y
Género Gender Female
Male
Trans female
Trans male
Intersex
Do not know
Other
Female
Male
Trans female
Trans male
Intersex
Do not know
Other
¿Cuál es su idioma predilecto? What is your preferred language?
* must provide value
English Inglés
Spanish Español
Other Otro
English Inglés
Spanish Español
Other Otro
Please enter your preferred language. * must provide value
Número de teléfono fiable: Reliable Phone Number * must provide value
Indique todo su disponibilidad para una llamada telefónica. Por favor, incluya todos los tiempos posibles. Lunes - Mañana (8 AM - 12 PM)
Lunes - Tarde (12 PM - 4 PM)
Lunes - Noche (4 PM - 8 PM)
Martes - Mañana (8 AM - 12 PM)
Martes - Tarde (12 PM - 4 PM)
Martes - Noche (4 PM - 8 PM)
Miércoles - Mañana (8 AM - 12 PM)
Miércoles - Tarde (12 PM - 4 PM)
Miércoles - Noche (4 PM - 8 PM)
Jueves - Mañana (8 AM - 12 PM)
Jueves - Tarde (12 PM - 4 PM)
Jueves - Noche (4 PM - 8 PM)
Viernes - Mañana (8 AM - 12 PM)
Viernes - Tarde (12 PM - 4 PM)
Viernes - Noche (4 PM - 8 PM)
Lunes - Mañana (8 AM - 12 PM)
Lunes - Tarde (12 PM - 4 PM)
Lunes - Noche (4 PM - 8 PM)
Martes - Mañana (8 AM - 12 PM)
Martes - Tarde (12 PM - 4 PM)
Martes - Noche (4 PM - 8 PM)
Miércoles - Mañana (8 AM - 12 PM)
Miércoles - Tarde (12 PM - 4 PM)
Miércoles - Noche (4 PM - 8 PM)
Jueves - Mañana (8 AM - 12 PM)
Jueves - Tarde (12 PM - 4 PM)
Jueves - Noche (4 PM - 8 PM)
Viernes - Mañana (8 AM - 12 PM)
Viernes - Tarde (12 PM - 4 PM)
Viernes - Noche (4 PM - 8 PM)
Condado/Direccion Direccion completa no es necesario para continuar.Por ejemplo: 1234 SW 1st Street, Gainesville, FL 99999 Si no es residente del condado Alachua, referir a otros recursos
¿Se resulta difícil encontrar transporte?
"Do you find it difficult to find transportation?"
If volunteer has concern for distance traveled by patient, please select yes. Yes
No
I would like to receive future updates by text message at my phone number above.
Me gustaría recibir noticias sobre las clínicas por mensaje de texto al número apuntado arriba. Please check "yes" if you are interested in being contacted by text message in the future. Messages will be limited to twice per week at most. Your contact information will not be shared, this choice will not impact the clinical care we provide, and you may opt out at any time.
Favor de marcar "sí" si le interesa estar contactado/a por mensajes de texto en el futuro. Mensajes estarán limitados a dos veces por semana al máximo. Su información de contacto no será compartido, esta decisión no afectará el cuidado medico que proveemos, y Ud. puede optar por no participar en cualquier momento. * must provide value
Yes
No
Volunteer Name Please select your name:
* must provide value
Laura Ramirez
Other
Please enter your name:
Your Email (UFL Email is preferable) * must provide value
Today's Date
Today M-D-Y
Ha recibido usted una prueba o diagnostico de coronavirus? Yes
No
Cuando recibido usted su prueba o diagnostico de coronavirus?* must provide value
Today M-D-Y
¿Cual fue el resultado? * must provide value
Negativo
Positivo
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
¿Tiene usted síntomas severos, incluyendo los de abajo?* must provide value
Cambio de color (azul o morado) en la cara o labios
Un dolor o presión en el pecho severo y constante
Falta de aire severo (mucho esfuerzo para respirar, incapaz de hablar por falta de aire, silbidos al respirar)
Episodios de confusión o desorientación (nuevas)
Pérdida de consciencia o incapaz de despertarse
Dificultad para hablar (nueva)
Episodios de convulsiones (nuevos)
Signos de presión baja (muy débil para pararse, mareos, piel pálida/frío/húmedo)
Deshidratación (sequedad en la boca o labios, disminución de las ganas de orinar, ojos hundidos o latidos cardiacos rápidos)
Ninguno de los de arriba
Cambio de color (azul o morado) en la cara o labios
Un dolor o presión en el pecho severo y constante
Falta de aire severo (mucho esfuerzo para respirar, incapaz de hablar por falta de aire, silbidos al respirar)
Episodios de confusión o desorientación (nuevas)
Pérdida de consciencia o incapaz de despertarse
Dificultad para hablar (nueva)
Episodios de convulsiones (nuevos)
Signos de presión baja (muy débil para pararse, mareos, piel pálida/frío/húmedo)
Deshidratación (sequedad en la boca o labios, disminución de las ganas de orinar, ojos hundidos o latidos cardiacos rápidos)
Ninguno de los de arriba
Days since test date: View equation
Caso confirmado: ¿En este momento, tiene usted síntomas de COVID-19?
Sintomas sin confirmacion de COVID-19: ¿Tiene usted síntomas de COVID-19 aunque no se ha confirmado un diagnostico?
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
¿Tiene usted los síntomas de abajo?
* must provide value
Fiebre o resfríos
Una tos persistente
Falta de aire
Garganta irritada o inflamada
Dolor y malestar muscular y articular
Dolor de cabeza
Vómitos y diarrea
Perdida de sentido olfato y del gusto
Congestión y goteo nasal
Ninguno de los de arriba
Fiebre o resfríos
Una tos persistente
Falta de aire
Garganta irritada o inflamada
Dolor y malestar muscular y articular
Dolor de cabeza
Vómitos y diarrea
Perdida de sentido olfato y del gusto
Congestión y goteo nasal
Ninguno de los de arriba
Síntomas no severos:
Please check all that apply. ¿Han pasado mas de 10 dias desde que empezaron los síntomas?
¿Los síntomas están mejorándose?
En las ultimas 24 horas, no ha tenido fiebre (sin tomar Tylenol).
¿Han pasado mas de 10 dias desde que empezaron los síntomas?
¿Los síntomas están mejorándose?
En las ultimas 24 horas, no ha tenido fiebre (sin tomar Tylenol).
Si han pasado 10 días (o mas), síntomas están mejorándose y no hay fiebre:
Aislamiento no necesario
Si han pasado 10 días (o mas), desde la fecha de su prueba, no tiene síntomas y no hay fiebre:
Aislamiento no necesario
¿En las ultimas dos semanas, ha usted tenido contacto o exposición con una persona con coronavirus? Yes
No
[Si usted le interesa estos recursos médicos, necesitamos un poco mas de información sobre su historia medica. Con su permiso, toda la próxima información será juntado y guardado en un sistema seguro.]
¿Tiene un doctor regular? Yes
No
¿Donde recibe usted cuidado medico?* must provide value
Le podemos referir a una clínica, Equal Access Clinic, por recursos médicas? Yes
No
¿Padece usted de otras condiciones o enfermedades?
[Por ejemplo - asma, diabetes, presión alta, enfermedad de los pulmones (EPOC), una enfermad que afecta el sistema inmune] Yes
No
¿Cuales?
[Por ejemplo - asma, diabetes, presión alta, enfermedad de los pulmones (EPOC), una enfermad que afecta el sistema inmune] asma
diabetes
presión alta
enfermedad de los pulmones (EPOC)
una enfermad que afecta el sistema inmune
otra condicion o enfermedad
asma
diabetes
presión alta
enfermedad de los pulmones (EPOC)
una enfermad que afecta el sistema inmune
otra condicion o enfermedad
¿Cuales otras?
¿Toma usted medicamentos para estas condiciones o otras condiciones medicas?
Yes
No
¿Cuales medicamentos? * must provide value
¿Necessita rellanar sus medicaciones? Yes
No
¿Usted fuma cigarrillos? Yes
No
¿Necesita usted ayuda con asuntos que no son médicos? Por ejemplo:
La nutrición
Ayuda financiera
Ayuda con asuntos legales (concern for repercussions from employer)
Otras necesidades
La nutrición
Ayuda financiera
Ayuda con asuntos legales (concern for repercussions from employer)
Otras necesidades
Detailes de asuntos legales:
Si tiene otras necesidades, cuales son?
Please call 911 to refer this patient to emergency services.
Add the patient to our followup worksheet. * must provide value
Confirm
Cancel
Si han sido mas de dos semanas desde el contacto (o mas de dos semanas desde que la persona tuvo COVID-19), no hay necesidad para prueba/aislamiento Sum qualifying factors for medical monitoring. (any value < 3 qualifies for MM). View equation
Calculate qualifying factors for testing View equation
Basándose en elegibilidad, podemos ofrecer los siguientes recursos:Prueba de COVID-19: Observación medica por el periodo de cuarentena: Medicamentos: ______ Cuidado medico a largo plazo: ______ Ayuda con la nutricion: Unchecked Ayuda financeria: Unchecked Ayuda con asuntos legales: Unchecked Otras necesidades: ______
Please confirm that the patient is being referred to medical monitoring.
Add the patient to our monitoring worksheet.* must provide value
Confirm
Cancel
Follow-Up Appointment Scheduled? Yes
No
Date for Follow-Up Appointment
Today M-D-Y
Thank you! Please 'submit' below to complete COVID-19 Spanish Hotline documentation. If followup is needed, the patient may expect a call from our hotline: (352) 327-8005 in the next 1-2 business days.
Your Name
Please type as First Name Last Name, Year. (Albert Gator, MS1)
* must provide value
Your UFL Email * must provide value
Clinic Location
* must provide value
Anthem Church
Eastside Clinic
Bartley Temple
Main Street Clinic
Other
Anthem Church
Eastside Clinic
Bartley Temple
Main Street Clinic
Other
What is your role? * must provide value
Medical Student Volunteer
Medical Student Officer
HOQI Intern
Medical Student Volunteer
Medical Student Officer
HOQI Intern
Officer Password
* must provide value
Disclaimer
Submit Password
Admin Use Only
Disclaimer
Officer Mode
Welcome ______ to Officer Mode!
You can use the options listed here to quickly access clinic forms and submission instructions.
Generate Personal Pre-Filled Clinic Navigator Link
URGENT: Contact Available Clinic Directors
View WeCare Submission Instructions
View UF Financial Assist. Instructions
View UF Health Department Fax Numbers
Generate Personal Pre-Filled Clinic Navigator Link
URGENT: Contact Available Clinic Directors
View WeCare Submission Instructions
View UF Financial Assist. Instructions
View UF Health Department Fax Numbers
Clinic Admin
Please select anything relevant for your patient and you will be provided with more information once you scroll down.
Follow Up
Your Name* must provide value
Scroll all the way to the bottom and enter the review tab to generate your custom link. Your Phone Number* must provide value
Reason for Contacting Directors
This will send a message to all clinic directors via twist and one will call you back.
Do NOT include PHI in this message.* must provide value
Send Urgent Director Message
* must provide value
Confirm
UF Health Department Fax Numbers
Clinic Director approval is required for access to fax numbers.
Clinic Director can enter password here and then click anywhere to proceed.
Disclaimer
UF Health Fax Numbers
Officer Mode Alert: Officer Mode will allow you to submit without entering patient information (ie to contact directors). If you are submitting a referral or order, be sure to select "Enter Patient Information" here. * must provide value
Enter Patient Information
No Patient Information Required for Submission
Enter Patient Information
No Patient Information Required for Submission
Patient Identification We identify patients using multiple identifiers. Please ensure they are all correct so we can complete all follow ups.
1) Patient Name Last Name, First Name
* must provide value
2) Patient Chart Link https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/______ /summary
Open the above highlighted link to confirm your patient's information is entered correctly. After logging in you should see your patient's chart.
* must provide value
Correct Patient
Chart Did Not Open Correctly
Correct Patient
Chart Did Not Open Correctly
Patient Chart Link Code This section should autofill but can be manually updated if instructed below , otherwise DO NOT EDIT.
* must provide value
Correct Patient Chart Link
1) Select Patient Chart Link as shown
2) 3) Patient PRN * must provide value
4) Patient Number As shown on the clinic tracker, should autofill, number 1-25.
* must provide value
Was the patient screened either today at clinic or via telehealth prior to this visit? * must provide value
Yes
No
Flu-like symptoms in last 14 days? * must provide value
Yes
No
Patient or close contact tested positive in last 14 days? * must provide value
Yes
No
Patient tested in last 14 days with results pending? * must provide value
Yes
No
Tested because patient or close contact were symptomatic? * must provide value
Yes
No
Has patient ever tested positive for COVID-19? * must provide value
Yes
No
Is the patient being referred to the Department of Health? Your patient has screened positive.
* must provide value
Yes
No
Officer Override Password
Disclaimer
Allow override? Yes
No
5) Patient Sex at Birth * must provide value
Female
Male
6) Patient Age * must provide value
7) Select patient BMI category * must provide value
Underweight (BMI < 18.5)
Normal (18.5 < BMI < 25)
Overweight or obese (BMI > 25)
Unsure
Underweight (BMI < 18.5)
Normal (18.5 < BMI < 25)
Overweight or obese (BMI > 25)
Unsure
8) Select patient's smoking status * must provide value
Never smoker
Current smoker
Former smoker
Unsure
Never smoker
Current smoker
Former smoker
Unsure
8a) >30 pack-year history? If unsure, leave blank.
Yes
No
8b) >30 pack-year history AND quit within last 15 years? Yes
No
9) Family history of colon cancer? If unsure, leave blank.
Yes
No
9a) Age of family member at CRC diagnosis If unsure, leave blank.
10) Patient's chronic medical conditions: Diabetes
Hyperlipidemia
Hypertension
Diabetes
Hyperlipidemia
Hypertension
11) Patient's 10-year ASCVD score (if able to calculate) http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
Only if patient has no history of heart attack or stroke!
< 5%
5 - 7.5%
7.5 - 10%
> 10%
Unable to calculate
< 5%
5 - 7.5%
7.5 - 10%
> 10%
Unable to calculate
AAA Screening needed? One-time abdominal ultrasound indicated.
* must provide value
Yes
No
Diabetes screening needed? Abnormal blood glucose screen is indicated.
* must provide value
Yes
No
Mammogram needed? Screening mammogram is indicated every 2 years.
* must provide value
Yes
No
Pap smear needed? Cervical cancer screening with Pap smear every 3 years is indicated.
* must provide value
Yes
No
Pap smear needed? Cervical cancer screening with Pap smear and HPV every 5 years OR Pap smear alone every 3 years is indicated.
* must provide value
Yes
No
FIT needed? Colorectal cancer screening with colonoscopy every 10 years OR cologuard every 3 years OR fecal occult blood test (FIT) every year is indicated.
* must provide value
Yes
No
Colonoscopy needed? High-risk colorectal cancer screening with colonoscopy every 5 years is indicated.
* must provide value
Yes
No
Gonorrhea/Chlamydia screen needed? G/C screening is indicated.
* must provide value
Yes
No
Behavorial counseling (social work) referral for weight loss needed? Weight loss intervention indicated.
* must provide value
Yes
No
HIV screening needed? HIV screening is indicated.
* must provide value
Yes
No
Low-dose CT needed? Lung cancer screening with low-dose CT every year is indicated.
* must provide value
Yes
No
DEXA scan needed? Osteoporosis screening with one-time DEXA bone scan is indicated.
* must provide value
Yes
No
Statin needed? Cardiovascular disease prevention with a statin is indicated.
* must provide value
Yes
No
Lipid panel needed? Lipid disorder screening is indicated.
* must provide value
Yes
No
HbA1c needed? Hemoglobin A1c every 3 months is indicated.
* must provide value
Yes
No
Updating the Patient's Preventative Health Measures If the preventative care section has been updated by a HOQI today, please input updated values below. If a lab has not been updated since last clinic visit, leave those fields blank.
To access lab values: "Timeline" >> Change "Encounters" to "Lab Results" in dropdown menu
Updated HbA1c Date
Today M-D-Y
Updated Lipid Panel Date
Today M-D-Y
Updated CRC Screening Date
Today M-D-Y
Which CRC screening test did patient undergo? * must provide value
Fecal Occult Blood Test (FIT)
Cologuard
Colonoscopy
Fecal Occult Blood Test (FIT)
Cologuard
Colonoscopy
Updated Mammogram Date
Today M-D-Y
Updated Pap Smear Date
Today M-D-Y
Updated Low-Dose CT Date
Today M-D-Y
Handoff
Please refer to the handoff sheet the undergraduate HOQI volunteer provided you and select the "Intake Screening Questions" they checked. Medically insured
Below the federal poverty line
Bus dependent
OT referral
PT referral
Colorectal cancer screening
Pap smear
Mammogram
Smoking cessation counseling
Alcohol overuse counseling
HIV testing
Intimate partner violence counseling
Psychology referral
Pharmacy referral (Medication reconciliation)
Dermatology referral
Dental referral
Eye clinic referral
Long-term contraceptive referral
Social work referral
Medically insured
Below the federal poverty line
Bus dependent
OT referral
PT referral
Colorectal cancer screening
Pap smear
Mammogram
Smoking cessation counseling
Alcohol overuse counseling
HIV testing
Intimate partner violence counseling
Psychology referral
Pharmacy referral (Medication reconciliation)
Dermatology referral
Dental referral
Eye clinic referral
Long-term contraceptive referral
Social work referral
Place Orders
You can select all the relevant orders and complete them in one submission.
Order Labs
Send a Referral
Order Imaging
Order Labs
Send a Referral
Order Imaging
Please select any labs you order: Lipid panel = ______
Pap and HPV = ______
* must provide value
BMP
CMP
Renal Function Panel
Hepatic Function Panel
CBC
Lipid panel
TSH
HbA1c
Free T4
ThinPrep Pap and/or HPV
Chlamydia/Gonorrhea RNA
RPR
4th Gen HIV Ag/Ab
Testosterone, Total
Estradiol, Free
SHBG
25(OH)-Vit D
Vit B12
Other
BMP
CMP
Renal Function Panel
Hepatic Function Panel
CBC
Lipid panel
TSH
HbA1c
Free T4
ThinPrep Pap and/or HPV
Chlamydia/Gonorrhea RNA
RPR
4th Gen HIV Ag/Ab
Testosterone, Total
Estradiol, Free
SHBG
25(OH)-Vit D
Vit B12
Other
Other Labs (please separate by commas)
Order Labs: Please see an officer. Labs are ordered in a separate system by officers. Referral Options Specialities without an EACN designation are not yet available within our network and the navigator will walk you through referring the patient to the best local resource.
Social work = ______
Allergy
Cardiology (EACN)
Dental (EACN)
Dermatology (EACN)
Diabetes Education Class (EACN)
Endocrinology
ENT
Hematology
General Surgery
GI
Gynecology (EACN)
Infectious Disease
LGBTQ Clinic (EACN)
Neurology
Neurosurgery
Nephrology
Obstetrics
Occupational Therapy (EACN)
Oncology
Ophthalmology Clinic (EACN)
Pediatric Occupational Therapy (EACN)
Pediatric Ophthalmology Clinic (EACN)
Pediatrics Night (EACN)
Pulmonology
Physical Therapy (EACN)
Psychiatry
Psychology (EACN)
Rheumatology (EACN)
Social Work (EACN)
Sleep Medicine
Smoking Cessation Class (EACN)
Spanish Night (EACN)
Urology
Allergy
Cardiology (EACN)
Dental (EACN)
Dermatology (EACN)
Diabetes Education Class (EACN)
Endocrinology
ENT
Hematology
General Surgery
GI
Gynecology (EACN)
Infectious Disease
LGBTQ Clinic (EACN)
Neurology
Neurosurgery
Nephrology
Obstetrics
Occupational Therapy (EACN)
Oncology
Ophthalmology Clinic (EACN)
Pediatric Occupational Therapy (EACN)
Pediatric Ophthalmology Clinic (EACN)
Pediatrics Night (EACN)
Pulmonology
Physical Therapy (EACN)
Psychiatry
Psychology (EACN)
Rheumatology (EACN)
Social Work (EACN)
Sleep Medicine
Smoking Cessation Class (EACN)
Spanish Night (EACN)
Urology
Reason for Referral Atrial fibrillation
Chest Pain
Coronary Artery Disease
Congestive Heart Failure
Poorly Controlled Hypertension
Request Holter Monitor for Diagnosis
Syncope
Symptomatic Angina
Unstable or New-Onset Angina
Valvular Disease
Atrial fibrillation
Chest Pain
Coronary Artery Disease
Congestive Heart Failure
Poorly Controlled Hypertension
Request Holter Monitor for Diagnosis
Syncope
Symptomatic Angina
Unstable or New-Onset Angina
Valvular Disease
Reason for Referral * must provide value
ASCVD risk >5% (and no history of ASCVD)
Asymptomatic cardiomegaly
Coronary artery disease
Documented abnormal ECG findings
History of arrhythmia: tachycardias/bradycardias/atrial fibrillation
History of CHF/suspected CHF
History of murmurs
History of myocardial Infarction
Hypertension + DM and/or dyslipidemia
Non-ACS chest pain (must obtain ECG prior to referring)
Persistent/significant symptoms (palpitations, shortness of breath, dizziness, etc)
Refractory hyperlipidemia/hypercholesterolemia
Refractory/secondary/severe hypertension
Suspected/confirmed valvular disease
Syncope (or presyncope)
Symptomatic angina
Unstable or new-onset angina
ASCVD risk >5% (and no history of ASCVD)
Asymptomatic cardiomegaly
Coronary artery disease
Documented abnormal ECG findings
History of arrhythmia: tachycardias/bradycardias/atrial fibrillation
History of CHF/suspected CHF
History of murmurs
History of myocardial Infarction
Hypertension + DM and/or dyslipidemia
Non-ACS chest pain (must obtain ECG prior to referring)
Persistent/significant symptoms (palpitations, shortness of breath, dizziness, etc)
Refractory hyperlipidemia/hypercholesterolemia
Refractory/secondary/severe hypertension
Suspected/confirmed valvular disease
Syncope (or presyncope)
Symptomatic angina
Unstable or new-onset angina
If your patient is experiencing or has experienced symptomatic angina, unstable or new-onset angina, or syncope with loss of conciousness they should be urgently evaluated in the Emergency Department.
If for some reason this does not describe your patient and both your attending & an officer agree that this patient does not require urgent evaluation but could benefit from cardiology evaluation in the coming months, an officer can enter their password below to continue.
Diagnostic Testing Needed Prior to Referral
Your patient needs diagnostic testing ordered (holter monitor, stress test, etc) and resulted prior to referral to cardiology night. Please utilize the out of network referral navigator (located below in clinic navigator) and discuss with an officer how to order these tests.
If these tests have already resulted and are uploaded to Practice Fusion, please see an officer, and after they confirm the patient is eligible for a referral, they can approve this referral by entering their password here.
Cardiology Referral Officer Override
Officers can enter their override password to continue with an EACN cardiology referral if the patient actually does meet eligibility criteria.
Disclaimer
Submit Password
Out of Network
Request Out of Network Appointment
Request Out of Network Appointment
Reason for Referral
Please provide additional information.
Confirm Appointment
Your patient is eligible for an appointment with our cardiology clinic.
Confirm EACN Appointment
Request Out of Network Appointment
Cancel
Confirm EACN Appointment
Request Out of Network Appointment
Cancel
Follow-Up Appointment Scheduled? * must provide value
Yes
No
Date for Follow-Up Appointment * must provide value
Today M-D-Y
Screening for Kardia Mobile Device Use Does patient meet criteria for a Kardia Mobile device (an FDA approved personal intermittent long-term cardiac monitoring device)? This includes the following: intermittent or potential atrial fibrillation, palpitations, premature ventricular contractions, tachycardia, bradycardia. Note: not recommended for use with pacemakers or for pediatric use.
Yes
No
Interest in Kardia Mobile Device Use Is the patient interested in using a Kardia Mobile Device?
Yes
No
Smartphone Compatibility for Kardia Mobile Device Use Does the patient have a smartphone (android or iOS phone) for use with the Kardia Mobile Device?
Yes
No
Eligible for Kardia Mobile Device Use Thank you, your patient is eligible for Kardia Mobile Device use. Further information will be provided to them at their EACN cardiology appointment.
Thank you! We have all the information we need for a cardiology referral and our cardiology team will follow up with the patient.
Please continue if you are placing other referrals or submit this sheet to finalize the referral. Who to Refer:
- Patients with diabetes mellitus who have either been recently diagnosed or could benefit from additional education regarding the disease and how to manage it.
Services offered:
The following is discussed in the class on the 2nd Thursday of the month:
- General risk factors
- Signs/symptoms
- Differences between the various types of diabetes
- General treatment and prevention information
- Complications
The following is discussed in the class on the 2nd Thursday of the month:
- Nutrition and Healthy Lifestyle
- Reading nutrition facts panel
- Different food groups and healthy options to choose from
- Exercise recommendations
- Online ADA resources
- Q&A session
Benefits to Patients
After patients attend one class, they may be eligible to receive a prescription from EACN for a free glucometer, test strips, and lancets from us.
Clinic Location and Times:
- When: 5pm-6pm on the 2nd and 4th Thursday of each month
- Where: Main Street Clinic
- Both Walk-Ins and Appointments are Accepted Would the patient like to request an appointment? Cancel
Confirm: Diabetes Education
Cancel
Confirm: Diabetes Education
Schedule an appointment:* must provide value
2nd Thursday
4th Thursday
Either
2nd Thursday
4th Thursday
Either
Is this an referral for routine dental care or urgent dental needs (active pain, etc)?* must provide value
Routine Care
Active Pain or Concern
Routine Care
Active Pain or Concern
This patient is eligible for dental services. We can refer them to our dental clinic, which currently has quite a backlog, or refer them to WeCare Dental Services.
Ask an officer which would be better for your patient. EACN Dental Clinic
WeCare: Dental
EACN Dental Clinic
WeCare: Dental
Patients are triaged and contacted by Dental Clinic staff. Our dental services are quite limited for patients without acute symptoms as our current wait list is over 300 patients long.
The patient may be eligible for free dental services though WeCare and they should be encouraged to call the WeCare Dental line at 352-334-7926 for information and scheduling.
No WeCare forms are required and the eligibility criteria is not as strict as other WeCare referrals.
Other Local Dental Resources WeCare Dental Resources
The patient should be encouraged to call the WeCare Dental line at 352-334-7926 for information and scheduling. No WeCare forms are required and the eligibility criteria is not as strict as other WeCare referrals. Reason for dental referral?
Please include chief complaint and description of pain.* must provide value
What is the patient's dental pain level?
Choose in increments of 10 with 100 being equal to a pain level of 10/10.
Thank you! We have all the information we need for a dental referral and our dental team will follow up with the patient.
Please continue if you are placing other referrals or submit this sheet to finalize the referral.
Dental Reason for Dermatology Clinic Referral?* must provide value
Suspicious lesion assessment, biopsy, and removal
Management of severe dermatological problems
Steroid Injection for a dermatologic disorder
Routine Skin Exam
Cosmetic Procedures
Other
Suspicious lesion assessment, biopsy, and removal
Management of severe dermatological problems
Steroid Injection for a dermatologic disorder
Routine Skin Exam
Cosmetic Procedures
Other
Lesion Picture
Take a photo of the skin lesion and upload it patient's chart (go to documents section on the PF homepage). Please note this is required for management of a skin lesion.* must provide value
Picture Uploaded
Picture Not Uploaded
Picture Not Applicable in this case
Picture Uploaded
Picture Not Uploaded
Picture Not Applicable in this case
Your patient does NOT appear to be eligible for a referral to dermatology.
Not Provided:
Routine skin exam in a patient without concerning findings
Cosmetic procedures, including botox
Management of skin conditions that can be treated in a primary care setting such as
Mild acne
Minor fungal Reason for Dermatology Referral* must provide value
Your patient is eligible for a referral to dermatology. * must provide value
Confirm Appointment: Derm
Cancel
Confirm Appointment: Derm
Cancel
Thank you! We have all the information we need for a dermatology referral and our dermatology team will follow up with the patient.
Please continue if you are placing other referrals or submit this sheet to finalize the referral. Equal Access Clinic Women's Night
Who to Refer:
Patients who require gynecologic care beyond what a primary care physician can handle. If patient only needs a routine Pap smear, they can be seen at any of the clinic sites that do Pap smears (Eastside or Main Street) on any night so that Women's Night spots can be reserved for patients who specifically need the expertise of an OB-GYN.
Services offered:
- Advanced gynecologic evaluation beyond what a PCP can handle.
- Endometrial biopsy
- IUD insertion / removal
- Depo Provera contraception
Clinic Location and Times:
- Main Street Clinic on the First Thursday of every month
- Appointments preferred, Walk-Ins are accepted Reason for Referral IUD Insertion/Removal
Depo-Provera
Nexplanon
Endometrial Biopsy
Pap Smear
Colposcopy
LEEP
Other
IUD Insertion/Removal
Depo-Provera
Nexplanon
Endometrial Biopsy
Pap Smear
Colposcopy
LEEP
Other
Additional Information
Your patient is eligible for an appointment with Women's Night. Confirm Appointment: Women's Night
Cancel
Confirm Appointment: Women's Night
Cancel
Pap smears and other general women's health are provided at our Eastside and Main Street primary care clinics and are NOT eligible for a refer to Women's Night.
We are currently unable to provide colposcopies, LEEP, and other complicated procedures at our network's Women's Night. Instead, the patient should be referred to a community provider through a network such as WeCare.
Continue with WeCare information below. Thank you! We have all the information we need for a women's night referral and our women's night team will follow up with the patient.
Please continue if you are placing other referrals or submit this sheet to finalize the referral. Reason for Referral? General Services
Hormone Therapy
General Services
Hormone Therapy
Hormone Therapy
Type of Therapy Requested Masculinization
Feminization
Masculinization
Feminization
Please ask a clinic officer to order (using the LGBT night order panel): CBC without diff, estradiol, total testosterone, and serum albumin. They do not need to order SHBG. Please ask a clinic officer to order (using the LGBT night order panel): estradiol, total testosterone, and a BMP. They do not need to order SHBG. LGBTQ occurs on the third Tuesday of every month at our Eastside clinic. We offer walk in and appointment services. We recommend patients arrive by 5:15 if they do not have an appointment. We do need their lab results to be able to begin HRT and these labs take much longer to be processed by Quest, so we recommend that they complete them at least 1 week before clinic. Please do not start therapy at clinic tonight without this information. LGBTQ clinic occurs on the third Tuesday of every month at our Eastside clinic. We offer walk in and appointment services. We recommend patients arrive by 5:15 if they do not have an appointment.* must provide value
Confirm Appointment: LGBTQ Night
Walk In
Confirm Appointment: LGBTQ Night
Walk In
Anything else we should know?
Is this a routine or urgent referral? Routine
Urgent
Additional referral options: 1) Alachua County Crisis Center
2) Meridian Behavioral Health
If you are feeling suicidal, depressed, anxious or have other urgent mental health concerns, call: The Crisis Line: (352) 374-5600, option 1
(NOTE: The Meridian Crisis Center is available 24 hours per day, 7 days per week, 365 days per year.)
Appointments:
New Clients (first time or 6+ months since last seen): (352) 374-5600, option 2
Returning Clients: (352) 374-5600, option 3
(NOTE: the Access Center is open from 7:30 a.m. to 6 p.m., Monday through Friday.)
Free Therapy Night Clinic Information Patients can call (352) 325-1775 to be scheduled for a telehealth appointment. Video is preferred , but phone services are also available.
Reason for referral
Your patient is eligible for a referral to psychology. Confirm Appointment: Psychology
Cancel
Confirm Appointment: Psychology
Cancel
Please have the patient call the clinic number above to make an appointment. They could also walk in, however appointments are recommended. Please recommend that the patient call the clinic as above to make an appointment. EACN does not provide obstetric services for pregnant women. Instead, we work to connect them with insurance and a regular OB provider.
Resources for Pregnant Patients (English)
Resources for Pregnant Patients (Spanish)
Would you like to refer the patient to social work? Yes
No
Who to Refer:
Patients who are experiencing any physical, mental, social/emotional, environmental or mobility limitations that prevent performance of daily activities (ex. dressing, eating, cooking, managing medications, housekeeping duties, etc.) and/or engagement in meaningful roles (ex. role as a caregiver, student, employee).
Services offered:
- Free Occupational Therapy services to people unable to afford treatment elsewhere.
- Provide Occupational Therapy evaluation and treatment, follow-up treatment visits, blood pressure and strength/flexibility screenings, referrals to specialists, and emergency medical referrals.
- Treat everyone in need of therapy care including; recent injury, postsurgical, preventative care, etc.
- CANNOT treat peds patients
Clinic Location and Times:
- We accept walk-in patients every Thursday from 6pm-8pm (excluding University holidays).
- 1621 SW 13th Street, above the CVS Patient Reminder Should our undergraduate team contact the patient to remind them about OT clinic?
Contact Patient
Cancel
Who to Refer:
Adults with significant vision loss, diabetics who have not been connected to eye care, and patients with a history of glaucoma.
Services offered:
Complete Exams: IOP (interocular pressure) measurements, slit lamp exams, dilated fundus exams
Screening: for cataracts, diabetic eye disease, glaucoma, retinal disease
Work-up: for acute eye problems (pain, vision change, trauma, etc)
Referral: to WeCare, Shands Charity Care
We do NOT offer refractions for glasses or contact lenses.
Clinic Location and Times:
When: Last Tuesday of each month, patients to arrive at 5:00 PM, patients are seen starting at 5:30 PM
Where: HealthStreet at 2401 SE Archer Rd, Gainesville, FL 32608
Does the patient have insurance? Yes
No
Does your patient have diabetes AND an A1C > 7.5? Yes
No
Does your patient have a family history of glaucoma? Yes
No
Has your patient recently experienced *significant* vision loss?
A need for updated glasses is NOT considered vision loss. Yes
No
When was the patients last eye exam? less than 1 year
1-2 years
more than 2 years
never
less than 1 year
1-2 years
more than 2 years
never
What is the patient's race? White
African American
Latino
Other
White
African American
Latino
Other
What is the patient's age? Less than 65 years old
65 years old or greater
Less than 65 years old
65 years old or greater
Your patient is eligible for a referral to ophthalmology.* must provide value
Confirm Appointment: Optho
Cancel
Confirm Appointment: Optho
Cancel
Please recommend that the patient call the clinic as above to make an appointment. Please follow the above prompts to determine the patient's eligibility for our Eye Clinic.
Unless a green thumbs up appears, your patient is not eligible for a referral to our ophthalmology clinic and you should instead refer to the below resources.
You can discuss this further with an officer and if they feel that the patient could still be eligible for a referral they can enter their override password below to continue with a referral.
What if my patient needs something not offered above?
This clinic does not offer refractions for glasses or contact lenses.
This clinic does not see pediatric patients.
For Medicaid patients, we are scheduling them at the UF Health Eye Clinic.
For patient's who can afford eye care we recommend refraction with a local optician or at their local Wal-Mart
For patients without resources and in need of refraction we recommend:
Alachua Department of Social Services- Provides vision exams and eyeglasses at low costs 218 SE 24thSt Gainesville, FL 32641 (352) 264- 6750www.alachuacounty.us M-F: 8:30am-4:30pm Eligibility: Must be an Alachua County resident and meet financial guidelines.
Gainesville Community Ministry Vision Clinic Provides eye exams and reconditioned eyeglasses, donations of $5 to cover cost of eyeglasses suggested. A Vision Clinic is offered every three months and is open to anyone. Call for information. 238 SW 4th Ave Gainesville, FL 32601 (352) 372-8162www.betterday.org M-R: 9:00am-2:30pm (main office) Eligibility: For uninsured Alachua County residents with no income/ working poor.
Helping Hands Clinic First United Methodist Church-Provides referrals for eye exams and eyeglasses for the homeless. 509 NE 1st ST Gainesville, FL 32601 (352) 519-5542www.hhcg.org M: 4:30PM-7:00PM WOMEN'S CLINIC: R: 3:00pm-7:00pm Eligibility: Must be homeless and in need of vision care.
Officer Override
Type password and wait for additional options. Do not press submit.
Disclaimer
Is the patient 18 years old or younger?
* must provide value
Yes
No
What indications for Peds OT does the patient have?
* must provide value
Neurodevelopmental disorder
Developmental delay (at risk or established)
Difficulty with ADLs (Activities of Daily Living)
Difficulty with IADLs (Instrumental Activities of Daily Living)
Lifestyle Modification Needs
Other the categories for referrals
Neurodevelopmental disorder
Developmental delay (at risk or established)
Difficulty with ADLs (Activities of Daily Living)
Difficulty with IADLs (Instrumental Activities of Daily Living)
Lifestyle Modification Needs
Other the categories for referrals
Please briefly describe "Other" indication
* must provide value
Your patient is eligible for a referral to Peds OT.* must provide value
Confirm Appointment: Peds OT
Cancel
Confirm Appointment: Peds OT
Cancel
Your patient will be contacted for scheduling an appointment, please make sure patient's contact info is up to date. Appointments will be held virtually on the first Wednesday of each month from 5:30-7:30pm.
Reason for Referral* must provide value
Your patient is eligible for a referral to pediatric ophthalmology.* must provide value
Confirm Appointment: Peds Ophtho
Cancel
Confirm Appointment: Peds Ophtho
Cancel
The patient will be contacted to schedule an appointment. Please confirm the patient's contact information in their chart. Who to Refer:
Any pediatric patient in need of medical care (including well child check-ups, school and sport physicals, and children who are sick)
Services offered:
- Well-child check-ups
- School physicals
- Sport physicals
- Sick child visits
Clinic Location and Times:
- When: The 1st and 4th Wednesday of each month at 5:30pm
Where: Bartley Temple United Methodist Church
1936 NE 8th Ave, Gainesville, FL 32641 Services Offered
Free Physical Therapy services to people unable to afford treatment elsewhere.
Provide Physical Therapy evaluation and treatment, follow-up treatment visits, blood pressure and strength/flexibility screenings, referrals to specialists, and emergency medical referrals.
Treat everyone in need of therapy care including; recent injury, postsurgical, preventative care, etc. - CANNOT treat peds patients
Please fill out the PT referral form and provide to the patient to bring to clinic. (They can still be seen without it, but only for one month)
Clinic Location and Times:
We accept walk-in patients every Thursday from 6pm-8pm (excluding University holidays).
1621 SW 13th Street, above the CVS
Patient Reminder
Should our undergraduate team contact the patient to remind them about PT clinic? Contact Patient
Cancel
Unfortunately, we do not yet have psychiatry services within EACN, nor does WeCare accept referrals for Psychiatry.
We can refer patients to the following local psychiatry services. See a clinic officer for a handout you can give patients. Reason for Referral
We are still working to finalize referral information for our new rheum clinic. We have all of the information we currently need and will reach out to the patient via phone.
Please ask an officer to order: CBC with diff, urinalysis without reflex culture, serum Cr, Hepatic Function Panel, ESR, Rheumatoid Factor, ANA, and TSH. Who to Refer:
Patients who are having concerns with going hungry, housing stability, child or elder care, transportation, bills (e.g. utilities), finding/maintaining work, intimate partner violence, or other social situations. Social work is particularly helpful for mental health resources. The patients should be identified via the intake process.
Services offered:
- One-on-one counseling appointment with Social Worker to discuss social needs
Clinic Locations:
- EAC Main Street
- UF Health Social Work (Monday - Friday 8am-4:30pm) Which location would the patient like to attend?
*Currently, EAC Social Work is only offered on select Thursdays at Main Street or by referral to the UF Health Medical Plaza Anthem (Certain Mondays)
Eastside (Certain Tuesdays)
Main Street (Certain Thursdays)
UF Health Medical Plaza
Anthem (Certain Mondays)
Eastside (Certain Tuesdays)
Main Street (Certain Thursdays)
UF Health Medical Plaza
Reason for Referral? Going hungry
Housing stability
Child and/or elder care
Transportation
Bills like utilities
Finding/maintaining work
Intimate partner violence
Dietary Intervention
Other
Going hungry
Housing stability
Child and/or elder care
Transportation
Bills like utilities
Finding/maintaining work
Intimate partner violence
Dietary Intervention
Other
UF Health Social Work
Located on the third floor of UF Health Med Plaza in the lobby of Medical Specialities.
Patients can walk in from 8am-4:30pm.
How urgent is this request? Routine
Urgent
Your patient is eligible for an appointment with social work. Confirm Appointment: Social Work
Cancel
Confirm Appointment: Social Work
Cancel
After filling out this form, your patient will be connected with one of the social workers that work with EAC. See our pharmacy team to place a referral. Who to Refer:
Patients who are having concerns with going hungry, housing stability, child or elder care, transportation, bills (e.g. utilities), finding/maintaining work, intimate partner violence, or other social situations. Social work is particularly helpful for mental health resources. The patients should be identified via the intake process.
Services offered:
- One-on-one counseling appointment with Social Worker to discuss social needs
Clinic Location and Times:
- Main Street: 1st & 3rd Thursdays of the Month
- Anthem: 2nd Monday of the Month
- UF Health Social Work: Monday - Friday 8am-4:30pm What type of imaging would you like to order?
Screening imaging (mammogram) = ______
Ultrasound (excluding cardiac)
Transthoracic Echocardiogram (Coming Soon)
Other Diagnostic Imaging
Screening Imaging
Ultrasound (excluding cardiac)
Transthoracic Echocardiogram (Coming Soon)
Other Diagnostic Imaging
Screening Imaging
Please indicate urgency of referral: Routine
Urgent
Please indicate the service requested:
*For adult patients needing imaging of uterus, ovaries, and adnexa, please order pelvic AND endovaginal. Abdominal Doppler
RUQ (liver, gallbladder)
Kidney Ultrasound
Total abdominal ultrasound (kidneys, liver, gallbladder, spleen, urinary bladder)
Scrotum
Upper Extremity Venous Ultrasound w/ Doppler
Lower Extremity Venous Ultrasound w/ Doppler
Soft Tissue Ultrasound
Thyroid
Pelvis (transabdominal for uterus, ovaries, adnexa)*
Endovaginal (uterus, ovaries, adnexa)*
Other
Abdominal Doppler
RUQ (liver, gallbladder)
Kidney Ultrasound
Total abdominal ultrasound (kidneys, liver, gallbladder, spleen, urinary bladder)
Scrotum
Upper Extremity Venous Ultrasound w/ Doppler
Lower Extremity Venous Ultrasound w/ Doppler
Soft Tissue Ultrasound
Thyroid
Pelvis (transabdominal for uterus, ovaries, adnexa)*
Endovaginal (uterus, ovaries, adnexa)*
Other
Laterality? Left
Right
Bilateral
Location* must provide value
Reason for exam* must provide value
Important Information for your Patient's Prep
- Greater than 10 years old: Do not eat or drink carbonated beverages 8 hours prior to exam or anything with cream/milk. Can have water, diabetics can have juice.
Younger than 10 yrs old:
- Newborn-4m: 2-3 h NPO,
- 4m-1yr: 4 h NPO;
- 1yr-6yrs: 6 h NPO3. Important Information for your Patient's Prep
Pelvis or Bladder: Drink approximately 32 ounces of water 1 hour before arrival time.
DO NOT use restroom. Patient's Primary Language* must provide value
Please update the patient's address in Practice Fusion as this is used to determine the location of the clinic bus for radiology night. Updated
Unknown
Your patient is eligible for a referral to our radiology clinic.* must provide value
Confirm Appointment: Radiology
Cancel
Confirm Appointment: Radiology
Cancel
The Radiology Clinic operates from the Mobile Outreach Clinic bus, and therefore the location can be flexible depending on patient needs.
The MOC Care Coordinator will choose a location that is closest to the majority of patients being referred. Once scheduled, patients will be contacted with the time and location of their appointment by the MOC Care Coordinator. Possible locations include Bartley Temple, UF Health Eastside Clinic, and Downtown Library.
Once referral is placed, an MOC Care Coordinator will schedule the patient for the next available Radiology clinic date and the patient will be contacted with the time/location of clinic.
Please select SUBMIT at the bottom of the page if you are finished. Which type of screening imaging would you like to order? Mammogram
Screening Mammogram Instructions
Ask an officer for this printed form and fill it out with a patient.
Officers, return the form to the interns to be faxed to the number on the form (NOT WeCare).
Out of Network Referral Options
We do not offer the specialty or test that you are requesting for your patient at this time, however after answering the following questions, you will be prompted to submit a referral to the appropriate local resource.
Insurance Status
Insured
Underinsured
Uninsured but age 65 or older / otherwise eligible for Medicare
Uninsured
Insured
Underinsured
Uninsured but age 65 or older / otherwise eligible for Medicare
Uninsured
Residency Status
Select all that apply US Citizen or Legal Resident
Alachua County Resident with valid home address
US Citizen or Legal Resident
Alachua County Resident with valid home address
Income Level
Below Poverty Level
Below 200% of Poverty Level
Above 200% of Poverty Level
Below Poverty Level
Below 200% of Poverty Level
Above 200% of Poverty Level
Reason for Referral
Diagnostic
Screening
Work-Related Injury?
Yes
No
WeCare Eligible
It appears that your patient is eligible for a WeCare referral! Please speak with a clinic officer to place the referral. (Specific referral instructions will appear in officer mode).
Please ensure the submission form includes the patient's ICD-10 diagnosis code.
WeCare Officer Submission Instructions
Print and fill out the following forms:
Example:
Instruct patient about what to expect with We Care
Hand patient a "We Care Info for Patients" sheet / (Spanish Version)
Inform patient that We Care will call them within 1-2 weeks and inform them if they are eligible - if they do not hear from them in this time, call the number on the sheet.
If eligible, We Care will give them additional instructions about how to proceed.
After completion of this step all of the necessary information from the patient has been obtained and the patient may leave.
Please speak with a clinic officer to place the referral. Confirm WeCare Referral
Cancel
Confirm WeCare Referral
Cancel
UF Health Financial Assistance Program Eligible
It appears that your patient is eligible for the UF Health Financial Assistance Program. Confirm UF FAP Referral
Cancel
Confirm UF FAP Referral
Cancel
UF Health Financial Assistance Program Officer Instructions
The patient should apply for the FAP with the forms attached below and submit to the atrium of the hospital. However, getting the specific referral to UF is where this gets complicated. We have not decided on an official protocol yet, so please discuss with your clinic director as they should have access to direct fax numbers for each UF Department. Patient Eligibility
Any patient who's total gross family income is less than 200% of the current federal poverty guidelines may be eligible for a full charity care discount (100%). Gross family includes all members of the immediate family and their dependents in the household. This includes any adult and, if married, a spouse and any natural or adopted minor children of said adults. United States Residents. Non-United States residents may be reviewed on an exception basis (emergent, urgent or traumatic care, but may not apply to aftercare / follow-up services).
Uninsured patients who are not eligible for assistance under the financial assistance policy may be eligible for a self-pay discount of 45% off of UF Health Shands' charges. The self-pay discount does not relieve nor forgive point-of-service cash payments that the patient may be required to pay. Also, the discount will not be applied to any "cosmetic" or other elective services.
UF Health FAP Application
FAP - Fax Cover Sheet
FAP - Application
FAP - Policy and Procedure Handout
FAP - Information for Patients
UF Health Financial Counselors are available at 352-265-0355 or toll free at 800-342-5364
In addition, financial assistance applications can be picked up free of charge at the following locations:
UF Health Shands Hospital Admissions Department Room 1331 (on the first floor between the Atrium and east entrances) 7 a.m. - Midnight Every day
UF Health Shands Cancer Hospital Admissions Department Room 1319 (off the lobby) 5:30 a.m. - 5 p.m. Monday through Friday
UF Health Shands Psychiatric and Rehab Hospitals Room 1110
UF Health Patient Financial Services 4024 NW 22nd Drive Gainesville, FL. 32605 8 a.m - 4:30 p.m Monday through Friday
Patients eligible for financial assistance at UF Health Shands will not be charged more for emergency or medically necessary care than amounts generally billed to patients having insurance under Medicare.
In Clinic Orders A1c = ______ , ______
FIT = ______
GC Swab = ______
HIV = ______
Lipid panel = ______
Pap = ______ , ______
Make sure any test completed at clinic for your patient is selected so the correct team can follow up on them.
Do NOT select anything you ordered for the patient to complete at Quest.
A1C
Biopsy
Colorectal Cancer Screening (FIT Test)
EKG
Flu Shot
GC Swab (Throat, Penile, Rectal, Vaginal)
Glucose
HIV
Lipid Panel
Pap Smear
Pregnancy
Rapid Strep
Urinalysis
A1C
Biopsy
Colorectal Cancer Screening (FIT Test)
EKG
Flu Shot
GC Swab (Throat, Penile, Rectal, Vaginal)
Glucose
HIV
Lipid Panel
Pap Smear
Pregnancy
Rapid Strep
Urinalysis
A1C/Glucose: Speak with the pharmacy team to have this test done.
Make sure to leave this option selected so we can keep track of the number of tests completed.
Order FIT Test: You can pick up a FIT testing kit from a clinic officer.
Discuss with the patient these instructions and ensure this form is returned to a clinic officer.
EKG/HIV/Pregnancy/Strep/Urinalysis: Speak with an officer to have this test done.
Make sure to leave this option selected so we can keep track of the number of tests completed.
Please see attached Flu Vaccine Administration Protocol See officer for assistance.
Eligibility: has not - or unsure if - received flu vaccine this year. Check FL SHOTS database prior to administration.
Contraindications: serious systemic/anaphylactic reaction to prior dose or its components
Provide patient with federal Vaccine Info Statement .
Document in Practice Fusion with Influenza Template and in FL SHOTS .
Administer Flulaval IM into deltoid muscle with supervision , monitor for reaction.
Speak with an officer to get the pap smear supplies, then complete the following information. Has the patient had a pap smear completed before? Yes
No
Has the patient ever had an abnormal pap before?* must provide value
Yes
No
What is the Lab Order number for the Pap Smear?* must provide value
How is the Pap Smear being transported to the lab? Please ask an officer if you are not sure.* must provide value
Transported by Medical Student Officer
Transported by HOQI
Transported by Medical Student Officer
Transported by HOQI
Who is transporting the pap smear?
Please ask an officer if you are not sure.* must provide value
Patient Identifiers
Are at least two different patient identifiers (name, PRN, birth date) written directly on the specimen bottle? If not, please add them.
* must provide value
Yes
Lab Order Form
Was the lab order form printed and included in the specimen bag? If not, please ask an officer to print it and place it in the bag.
* must provide value
Yes
Lab Specimen
Select all that apply.
Dermatology Biopsy
Radiology Night Biopsy
Women's Night Biopsy
GC Swab (Oral)
GC Swab (Penile)
GC Swab (Rectal)
GC Swab (Vaginal)
Other
Dermatology Biopsy
Radiology Night Biopsy
Women's Night Biopsy
GC Swab (Oral)
GC Swab (Penile)
GC Swab (Rectal)
GC Swab (Vaginal)
Other
Lab Specimen
Describe if needed
Patient Identifiers
Are at least two different patient identifiers (name, PRN, birth date) written directly on the specimen bottle? If not, please add them.
* must provide value
Yes
Lab Order Form
Was the lab order form printed and included in the specimen bag? If not, please ask an officer to print it and place it in the bag.
* must provide value
Yes
Lab Specimen Order Number
If multiple separate by commas.
* must provide value
Which lab will the biopsy be sent to?* must provide value
Quest
UF Pathlabs
How is the biopsy being transported to the lab? Please ask an officer if you are not sure.* must provide value
Transported by Medical Student Officer
Transported by HOQI
Transported by Medical Student Officer
Transported by HOQI
Biopsy Transported by who?* must provide value
Clinic Protocols
Make sure anything completed at clinic for your patient is selected so the correct team can follow up on them.
Please select anything relevant for your patient and you will be provided with more information once you scroll down.
Baker Act
Prescribe HIV Pre-Exposure Prophylaxis
Prescribe: Long-Acting, Reversible Contraception
Request Outside Records
Baker Act
Prescribe HIV Pre-Exposure Prophylaxis
Prescribe: Long-Acting, Reversible Contraception
Request Outside Records
Additional Eastside Options Gender Affirming Therapy
If you are even thinking about a Baker Act,
please see an officer immediately.
Leave this option checked upon submitting if a Baker Act was submitted.
A clinic director needs to notified immediately if you are implementing this protocol.
Please call another director if yours is unavailable.
Overview of Protocol
Patient tells medical or undergraduate student that they are a threat to themselves or others.
Medical student or undergraduate student IMMEDIATELY notifies site officer or attending.
Attending is IMMEDIATELY notified and takes lead over the rest of the visit
Medical student or HOQI volunteer waits outside patient room and if patient attempts to leave, student tells patient we would still like to speak with them and asks them to stay but does not attempt to physically restrain the patient if they decide to leave.
Medical student officer provides attending with copy of State of Florida Baker Act form and remains available to attending
Attending conducts a through evaluation of the patient (inquires about suicidal thoughts, plans, behaviors, and completes a full psychiatric ROS) and feels as though the patient is a threat to themselves or others with an active plan .
Attending expresses concern about patient and offers them voluntary commitment.
Patient refuses voluntary commitment.
Attending completes Baker Act Form --> see below to determine where GPD should transport pt 7. Medical student or HOQI volunteer remains with patient, preferably in the room, and if they attempt to leave inform them that they have been placed under an involuntary commitment and must stay. Do not attempt to physically restrain the patient and instead inform them that if they leave GPD will come looking for them.
8. Photo copy Baker Form, upload to PF chart after faxing it as above, and provide original to GP
9. Police arrive and form goes with patient and police
10. Document the encounter, including above sections
***How do we transport a patient to a facility for voluntary commitment?
Unfortunately, there is not a good way to do this and ultimately a Baker Act Form must be signed to get them transported by police. Call 911 and tell them that they are voluntary, but need transport. When police arrive, remind them and ask the patient not be restrained/handcuffed.
What should I do if the patient leaves after seeing the attending?
If the attending felt as though the patient met Baker Act criteria, they can sign the Baker Act Form and call 911. The police will collect them.
What should I do if the patient expresses SI/HI to a HOQI or medical student and leaves before an attending sees them?
The HOQI or student should notify the attending immediately so that they can weigh in on how severe the statement was. However, an attending cannot sign a Baker Act Form for a patient they did not evaluate. Instead, if the attending agrees, call the police and explain the situation and ask for a safety check on the patient.
What should I do if I feel uncomfortable with examining the patient?
Don't examine them! That's okay. Just document what you can see and mental status exam if applicable.
Last updated: June 2019
Sources used include: https://www.myflfamilies.com/service-programs/samh/crisis-services/laws/bainvex.pdf
https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.53.9.1171
https://www.myflfamilies.com/service-programs/samh/crisis-services/laws/BakerActManual.pdf
Patient Release Form
Please obtain our medical records release form from a clinic officer.
You only need to print and fill out the second page with the patient. The release PHI from section should include the name of the clinic we are requesting records from and the release PHI to section should state "UF Equal Access Clinic" with the fax number 352-627-4141.
Give the completed and signed form to a clinic officer, who will ensure it gets to our office staff for faxing.
Clinic or Hospital Requesting Records From
Please type the full name of the hospital or clinic you are requesting records from for continuing care.
Type of Records Requested
Pre-Exposure Prophylaxis * must provide value
Consultation
Initiation
Follow-Up
Consultation
Initiation
Follow-Up
PrEP Labs Please see an officer to order the following labs:
HIV immunoassay blood test BMP (renal function) Hepatitis serology These labs should be ordered and completed at least one full week prior to clinic visit (these labs are sent across the country and take a while for Quest to process). We typically order labs at each visit for the follow up visit.
PrEP Information Please select the following risk factors your patient has: See above (risk factors section)
* must provide value
MSM (men who have sex with men)
Heterosexually active
Persons who inject drugs
MSM (men who have sex with men)
Heterosexually active
Persons who inject drugs
Patient HIV Status * must provide value
Positive
Negative
Patient Renal Function (eGFR) * must provide value
Patient HBV Status * must provide value
Positive
Negative
Patient HCV Status * must provide value
Positive
Negative
Does the patient meet clinical eligibility per the chart above? Yes
No
Your patient meets eligibility criteria for PrEP! Please do not prescribe more than a 3 month supply.
See our pharmacy team for more information applying for a prescription assistance program.
Please enter the PrEP prescription for your patient. * must provide value
Your patient needs to have documented negative laboratory testing before PrEP can be prescribed.
Please ask a clinic officer to order a 4th generation HIV test, serum Cr, and hepatitis serologies (using order panel) tonight and have the patient return at least 2 days after getting labs done. Please see an officer to order the following labs: HIV immunoassay blood test Indicated STI testing (G/C/Syphilis) These labs should be ordered and completed at least one full week prior to clinic visit (sent across country and take a while for Quest to process). We typically order labs at each visit for the follow-up visit.
Has the patient had PrEP prescribed with EACN before? Yes
No
Follow-Up Information
Date Last Labs Were Drawn * must provide value
Today M-D-Y
Latest HIV Status * must provide value
Positive
Negative
Latest Gonorrhea Result Positive
Negative
Latest Chlamydia Result Positive
Negative
Latest Syphilis Result Positive
Negative
Latest eGFR * must provide value
Please see an officer to order the following labs: HIV immunoassay blood test Indicated STI testing (G/C/Syphilis) BMP (renal function) These labs should be ordered and completed at least one full week prior to clinic visit (sent across country and take a while for Quest to process). We typically order labs at each visit for the follow-up visit.
Has your patient had a recent documented negative Hepatitis B and C serologies? Yes
No
Did you prescribe PrEP? Yes
No
Type of LARC Administered
Select the type of LARC only if it was administered or placed in clinic today. If you referred a patient to Women's Night to have LARC completed, return to patient follow up and uncheck the LARC option. Women's Night will document it once it has been placed.
Copper IUD
Depo-Provera Injection
Mirena IUD
Nexplanon
Copper IUD
Depo-Provera Injection
Mirena IUD
Nexplanon
Did an LGBTQ officer ask you to complete this section? Yes
No
LGBTQ Officer Password* must provide value
Disclaimer
Date of most recent patient follow-up Office visit, telemedicine visit, phone call (may include today's clinic visit)
* must provide value
Today M-D-Y
Does patient use tobacco? * must provide value
Yes
No
Packs per day * must provide value
Does patient drink alcohol? * must provide value
Yes
No
Standard drinks per week 12oz beer, 5oz wine, 1.5oz liquor
* must provide value
Select any additional substances patient uses Cannabis
Cocaine
Amphetamines
Sedatives
MDMA (Ecstasy)
Other
Cannabis
Cocaine
Amphetamines
Sedatives
MDMA (Ecstasy)
Other
Please specify other substances * must provide value
Select any prior mental health diagnosis patient endorses Generalized anxiety disorder
Major depressive disorder
Bipolar disorder
Attention Deficit (Hyperactive) Disorder
Eating disorders
Other
Generalized anxiety disorder
Major depressive disorder
Bipolar disorder
Attention Deficit (Hyperactive) Disorder
Eating disorders
Other
Please specify other psychiatric diagnoses * must provide value
Patient's PHQ-9 score this visit (If indicated)
Gender Affirming Therapy
The following questions will provide you with information on how to best care for our patients requesting gender affirming therapy and will allow our team to follow up with them.
Please select the type of visit desired.
Initial Consultation
Initiation of Therapy
Continuation of Therapy
Initial Consultation
Initiation of Therapy
Continuation of Therapy
Therapy Desired * must provide value
Masculinization
Feminization
Masculinization
Feminization
Gender Affirming Therapy Protocol for Women Gender Affirming Therapy Protocol for Men Masculinization Labs
Please see an officer to order the following labs:
CBC without diff (Hg and Hct for erythropoietic effect)
Serum Estradiol (not total estradiol)
Serum Total Testosterone LC/MS/MS (free testosterone unreliable [33]
Serum Albumin
These labs should ordered and completed at least one full week prior to clinic visit (these labs are sent across the country and take awhile for Quest to process). We typically order labs at each visit for the follow up visit.
Feminizing Labs
Please see an officer to order the following labs:
Serum Estradiol (NOT TOTAL estradiol)
Serum TOTAL testosterone LC/MS/MS
CMP
These labs should ordered and completed at least one full week prior to clinic visit (these labs are sent across the country and take awhile for Quest to process). We typically order labs at each visit for the follow up visit.
Date Current Labs Ordered
Click today if labs were ordered today. We typically order labs at each visit, if for some reason you do not want to order labs, please discuss with an officer before the patient leaves.
Today M-D-Y
Informed Consent
Please discuss the informed consent form for Gender Affirming Therapy with the patient. We typically recommend giving the informed consent to the patient to review and return at the initiation of therapy visit.
It must be signed and scanned into the patient's chart (see an officer) prior to prescribing therapy.
Given to Patient
Signed and Collected
Already Signed and in PF
Given to Patient
Signed and Collected
Already Signed and in PF
Informed Consent
Please select the date the patient's informed consent was uploaded to PF.
Today M-D-Y
Initation of Therapy
Please select when the patient was started on therapy. Select today if this is the initation visit, if not check their chart for when they were started on therapy and select that here.
* must provide value
Today M-D-Y
Therapeutic Lab Levels
Please review the patient's most recent labs and enter them here for follow up.
Most Recent Lab Results
Please use the most recent lab results and select the day the labs were drawn , not ordered.
Today M-D-Y
Testosterone
Most recent testosterone level (ng/dL)
Estradiol
Most recent estradiol level (ng/dL)
Albumin
Most recent albumin level
Hemoglobin
Most recent hemoglobin level
Patient Satisfaction
Are the patient's therapeutic expectations being met?
Yes
No
Medication and Dosage
old not used
Masculinization Therapy
Please select the medication and dose prescribed today.
Testosterone Cypionate 50mg q weekly
Testosterone Cypionate 50mg twice weekly
Other
Testosterone Cypionate 50mg q weekly
Testosterone Cypionate 50mg twice weekly
Other
Feminizing Therapy
Please select the medication and dose prescribed today.
Estradiol, PO, 1mg qd
Estradiol, PO, 2mg qd
Estradiol, PO, 1mg BID
Estradiol, PO, 2mg BID
Estradiol, PO, 4mg qd
Estradiol, PO, 4mg BID
Other
Estradiol, PO, 1mg qd
Estradiol, PO, 2mg qd
Estradiol, PO, 1mg BID
Estradiol, PO, 2mg BID
Estradiol, PO, 4mg qd
Estradiol, PO, 4mg BID
Other
Other, include medication and dose
How was the medication prescribed? * must provide value
Written Prescription
Called into Pharmacy
Written Prescription
Called into Pharmacy
Date prescription was called into pharmacy
Today M-D-Y
Who called it into the pharmacy? Name, Year
* must provide value
If patient has stopped receiving care from us, why? Patient moved
Patient seeing another provider
Patient elected to discontinue therapy
Other
Patient moved
Patient seeing another provider
Patient elected to discontinue therapy
Other
Please specify reason
3) Retest link above and select confirm if it now works. If not, see an officer and they may instruct you to use the PRN field below. Lab Link
Select to Enter Patient Information for Submission > * must provide value
Enter Patient Information
Enter Patient Information
Reason for Visit
Wellness/Preventive Care Visit
Sick Visit
Chronic Condition Management
Hospital/ED Follow Up
Wellness/Preventive Care Visit
Sick Visit
Chronic Condition Management
Hospital/ED Follow Up
Patient Type General Patient
Spanish-Night Patient
General Patient
Spanish-Night Patient
Patient Type
Select General, LGBTQ, OR Dermatology.
Social Work should be selected (alone or with one of the other options only if the patient was seen by a Social Worker tonight, not referred to SW.) General Patient
LGBTQ Patient
Dermatology Patient
Social Work Patient
General Patient
LGBTQ Patient
Dermatology Patient
Social Work Patient
Patient Type Adult Patient
Pediatric Patient
Adult Patient
Pediatric Patient
Patient Type General Patient
Women's Night Patient
Social Work Patient
General Patient
Women's Night Patient
Social Work Patient
Date of Clinic * must provide value
Today M-D-Y
Attending First and Last Name
Example: Ryan Nall, MD
* must provide value
Resident First and Last Name
(If a resident was involved in this patient's care)
Example: Robert Case, MD
Clinic Tracker Times
Please enter the time (hours:minutes) that is listed on the clinic tracker once the patient's status is updated to "Patient Seen & Left." Clinic Tracker Times: Total Time
Please enter the time (hours:minutes) that is listed on the clinic tracker once the patient's status is updated to "Patient Seen & Left." * must provide value
H:M
Clinic Tracker Times: Intake (HOQI) Time
Please enter the time (hours:minutes) that is listed on the clinic tracker once the patient's status is updated to "Patient Seen & Left." * must provide value
H:M
Clinic Tracker Times: Medical Student Time
Please enter the time (hours:minutes) that is listed on the clinic tracker once the patient's status is updated to "Patient Seen & Left." * must provide value
H:M
Clinic Tracker Times: Waiting to Present Time
Please enter the time (hours:minutes) that is listed on the clinic tracker once the patient's status is updated to "Patient Seen & Left." * must provide value
H:M
Custom Officer Link
1) Enter your information into the Volunteer Name, Volunteer Email, Officer Approved Name, and Officer Approved Email Above
2) Bookmark the generated link below for your specific clinic
3) Do not share your link with anyone else, when selected it will automatically log you into officer mode and input your information
Anthem: https://redcap.ctsi.ufl.edu/redcap/surveys/?s=AWRLDATDN9&nonproduction=overridestaffaccess&clinic_location=1&user_role=2&user_officer_password=careforall&officer_approved=______ &officer_approved_email=______ &volunteer_name=______ &volunteer_email=______
Eastside: https://redcap.ctsi.ufl.edu/redcap/surveys/?s=AWRLDATDN9&nonproduction=overridestaffaccess&clinic_location=2&user_role=2&user_officer_password=careforall&officer_approved=______ &officer_approved_email=______ &volunteer_name=______ &volunteer_email=______
Bartley Temple: https://redcap.ctsi.ufl.edu/redcap/surveys/?s=AWRLDATDN9&nonproduction=overridestaffaccess&clinic_location=3&user_role=2&user_officer_password=careforall&officer_approved=______ &officer_approved_email=______ &volunteer_name=______ &volunteer_email=______
Main Street: https://redcap.ctsi.ufl.edu/redcap/surveys/?s=AWRLDATDN9&nonproduction=overridestaffaccess&clinic_location=4&user_role=2&user_officer_password=careforall&officer_approved=______ &officer_approved_email=______ &volunteer_name=______ &volunteer_email=______
Type of After Visit Summary Patients must sign an email PHI release to use email.
Email
Print
None
Patient Email The patient's email can ONLY be entered here if they have signed an email specific PHI release form.
Custom Text Entry
HYTQ Custom Text Will appear red and highlighted
Ordering Labs? If yes , copy and paste the green text below into the box to the right.
Your physician and medical student have ordered laboratory tests to be done before the next visit.
Your labs can be done at any Quest location and will be free if you provide them with the order number below.
If no , copy and paste the red text below into the box to the right.
You do not need to complete any labs.
Quest Order Number Please obtain from an officer.
Equal Access Clinic Network After Visit Summary ______ ______ In case of an emergency, please call 911. Please do not reply to the email. Return emails are not monitored.
For general questions, please call our office Monday - Friday from 9am to 4pm. Office: 352-273-9425 | Fax: 352-627-4141 equalaccess.med.ufl.edu
Dear Patient,
Thank you for visiting our ______ tonight. You were seen by ______ and Dr. ______ .
______
______
Medications
______
Blood Work
______
Lab Order Number: ______
Monday Night, 5:30pm
Tuesday Night, 5:30pm
UF Health Eastside Clinic
410 NE Waldo Road, Gainesville, FL 32641
1936 NE 8th Ave, Gainesville, FL 32641
In case of an emergency, please call 911. Please do not reply to the email. Return emails are not monitored. Review Patient and Volunteer Information Patient: ______ was seen at ______ on ______ and is patient ______ on the clinic tracker.
Medical Student Volunteer: ______ (______ ) blank if seen by Officer
EACN Officer Contact: ______ (______ )
Review Clinic Navigator Submission Please confirm that everything below is correct.
Requested appointments will appear highlighted and say "Confirm".
Any blank highlighted lines simply means you did not refer your patient there.
Requested In Network Appointments
Cardiology: ______ Diabetes Education: ______ Dental: ______ (routine dental appointment requests are not included here) Dermatology: ______ Gynecology: ______ LGBTQ Clinic: ______ Mental Health: ______ Ophthalmology: ______ Peds Ophthalmology: ______ Physical Therapy: ______ Social Work: ______ Radiology: ______ for ______
Out of Network Referrals
Actual referrals are submitted by an officer, so be sure to discuss with them.
WeCare: ______
UF Health: ______
In Clinic Services Completed
______
______
Once you confirm all information is correct the form will automatically ask you to submit.
You will receive a confirmation email and copy of each referral.
Officer Approved
Which officer personally approved each referral you are about to submit?
Please type as name, year.
* must provide value
Officer Email
Please enter the email of the officer listed above. You can access their emails here .
* must provide value
All above information is CORRECT and FINALIZED
Selecting "Confirm Correct" will finalize all information and submit all referrals and alerts .
If for any reason you make a mistake after submitting, you must see an officer.
* must provide value
Confirm Correct
EXPLORING MODE
DO NOT PRESS SUBMIT
Do not attempt to submit, as the form will not be accepted without officer permissions, even if a green bar appears.
EXPLORING MODE
DO NOT PRESS SUBMIT
READY FOR SUBMISSION
Please press submit to finalize your submission.
Please contact a clinic officer if you need to change anything previously submitted.
DO NOT PRESS SUBMIT
Once you have finished inputting referrals and the tasks completed for your patient, you must review the section titled "Review Submission."
This box will disappear when you are ready for submission.
Submit
Save & Return Later