Form Generator -Â Please do not edit
* must provide value
Full Name Nombre completo: * must provide value
Date of Birth Fecha de nacimiento:Â * 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 clÃnica de Equal Access anteriormente? * must provide value
Yes, at a primary care clinic
Yes, at the physical therapy clinic
No
Yes, at a primary care clinic
Yes, at the physical therapy clinic
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: establish care, medication refill, follow up on labs, physical therapy, etc.Ejemplos: establecer atención médica, resurtido de medicamento, 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 sÃntoma nuevo desde la última visita? * must provide value
Yes
No
What is your preferred language? ¿Cuál es su idioma predilecto? Â
* must provide value
English
Español
Other (Otro)
English
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
Indique todo su disponibilidad para una llamada telefónica. Por favor, incluya todos los tiempos posibles. * must provide value
I would like to receive updates about the Equal Access Clinic Network (EACN) by text message at my phone number above.
Me gustarÃa recibir noticias sobre la red de clÃnicas 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 "sÃ" 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.
Your Name Please type as First Last, Year
* must provide value
7th Day
Eastside
Bartley Temple
Main Street
Derm Clinic
Health Fair
Other
Anthem Church
7th Day
Eastside
Bartley Temple
Main Street
Derm Clinic
Health Fair
Other
Anthem Church
Please indicate name of site: e.g. "MOC" for Mobile Outreach Clinic
Medical Student Volunteer
Medical Student Officer
Outside Referral
Derm Clinic Volunteer
HOQI Intern
Research Volunteer
Medical Student Volunteer
Medical Student Officer
Outside Referral
Derm Clinic Volunteer
HOQI Intern
Research Volunteer
Officer Password * must provide value
Disclaimer
Submit Password
Disclaimer
Patient Name Last name, First name
* must provide value
Patient Number As shown on the clinic tracker, should autofill, number 1-25.
* must provide value
Outside Referral Mode Alert: Â Â Outside Referral Mode will allow you to refer a patient to one of our primary care or specialty clinics. Â
* must provide value
Proceed to Referral
To which clinic would you like to refer this patient? * must provide value
Prenatal night
Name individual making referral:
* must provide value
Email of individual making referral:
* must provide value
Today M-D-Y
Officer Override Password Disclaimer
Yes
No
Female
Male
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
Select patient's smoking status * must provide value
Never smoker
Current smoker
Former smoker
Unsure
Never smoker
Current smoker
Former smoker
Unsure
>30 pack-year history? If unsure, leave blank.
Yes
No
>30 pack-year history AND quit within last 15 years? Yes
No
Colon cancer screening: is the patient experiencing any of the following symptoms? - Blood in stool - Urge to defecate without ability to do so - New onset fatigue - New onset anemia - Unintentional weight loss - Persistent abdominal pain, bloating, or back pain Yes
No
Family history of colon cancer? If unsure, leave blank.
Yes
No
Age of family member at CRC diagnosis If unsure, leave blank.
Patient's chronic medical conditions:
Please select the services utilitized this clinic: Select all that apply. Leave blank if none apply.
(This information will be used for the CHOICES grant)
< 5%
5 - 7.5%
7.5 - 10%
> 10%
Unable to calculate
< 5%
5 - 7.5%
7.5 - 10%
> 10%
Unable to calculate
Diabetic retinopathy screening needed? Has the patient had a dilated eye exam in the last 12 months? No
Yes
Unsure
AAA Screening needed? One-time abdominal ultrasound indicated.
* must provide value
Yes
No
Mammogram needed? Screening mammogram is indicated every 2 years after the age of 40. Mammograms are followed up by our Gynecology Night officers - but any clinic may refer a patient for a mammogram! * must provide value
Yes
No
Pap smear needed? Pap smear alone every 3 years is indicated.
* must provide value
Yes
No
Pap smear needed? Pap smear & HPV every 5 years
OR
Pap smear alone every 3 years
* must provide value
Yes
No
FIT needed? Your patient may qualify for FIT screening. Please confirm that at least one of the following is true:
Asymptomatic patients aged 45-75 years old Patients of any age with symptoms concerning for potential malignancy: Blood in stool or bleeding from rectum Change in bowel habits, urge to defecate without ability to do so  New onset fatigue or weakness Anemia Unintentional weight loss Persistent abdominal cramping, bloating, or low back pain Patients with a previous history of colorectal cancer who have not been screened in the past year Patients with a family history of colorectal cancer either: Beginning at age 40 10 years before the age of diagnosis of a family member (eg screening an asymptomatic 27 year old patient whose father was diagnosed at age 37) Patients age 76-85 that are identified as benefitting from screening based on individualized discussion with providers * must provide value
Yes
No
Colonoscopy needed? High-risk colorectal cancer screening with colonoscopy every 5 years is indicated.
* must provide value
Yes
No
HIV screening needed? HIV screening may be indicated.
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
Does the patient have a diagnosis of asthma? Yes
No
WIC Screening: Would the child benefit from nutritional support? Mothers of infants (< 1y) qualify for lactation counseling, breastfeeding supplies, and other means of lactation support.
Children aged 1-5 qualify for monthly food packages tailored to support growth and development.
Yes
No
Thank you! The patient's information will be passed on to a WIC representative for in order to connect them to WIC resources. Does the patient need urgent asthma management or routine care?
Urgent management
Routine care
Urgent management
Routine care
When was the patient last evaluated for asthma?
Today M-D-Y
What medications does the patient CURRENTLY take for asthma?
Positive screening for intimate partner violence?Select "yes" if the patient responded "yes" to any one of the following questions:
"Is there currently anyone in your life who tries to control you?"
"Is there currently anyone in your life who you are afraid of?"
"Is there currently anyone in your life who threatens you?"
* must provide value
Yes
No
Interested in social work referral for intimate partner violence? If your patient screened positive for IPV, please offer a social work referral and/or consider offering other IPV resource information.
* must provide value
Yes
No
Language interpreter use Was an interpreter used during your patient encounter?
Yes
No
What type of interpreter did you use today?
(Select all that apply)Â
Name of student interpreting:
What language was needed today?
Spanish Haitian Kreyól Portuguese Indigenous languages (e.g., Q'anjob'al, Mixtec, etc.) Mandarin Chinese Cantonese Vietnamese Arabic French Russian Korean Other
Please specify the language needed:
Technical Issues & Barriers Did you experience any technical issues while using the interpreter line? (e.g. connectivity, delays during the call, dropped calls, etc)
Yes
No
Were there any language barriers or difficulties in understanding the interpreter?
Yes
No
Please describe the issue you encountered using the Language Line:
Responses will be forwarded to the Language Services Team so that we may continue to improve our interpretting services!Â
Place Orders Â
You can select all the relevant orders and complete them in this same submission.
Please select any labs you order: * must provide value
Other labs ordered: Separate labs by commas
To Order Labs: Please see the labs 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.
Is the patient interested in being referred for tobacco cessation? You identified this patient as being a 'current smoker'
* must provide value
Yes
Not at this time
Patient's preferred method of being contacted?
Select all that apply.
AHEC Smoking Cessation
If the patient prefers to reach out to AHEC for resources/support, please provide them with the following phone number:Â
(877) 848-6696Â
Â
AHEC services:
Free virtual group quit sessions 2 week starter kits of nicotine patches or gum 24/7 telephone Quit Coach Personalized Quit Plan
Thank you! We have all the information we need for a AHEC Smoking Cessation AHEC Smoking Cessation  team will follow up with the patient. Reason for Cardiology Referral: Â
Note: Please speak to an officer if the ONLYÂ reason you are placing a referral is for the completion of an EKG . Some clinic sites are able to perform EKGs in-clinic.Â
* 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. Â
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 Â
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
Any additional information regarding Cardiology Referral?
Your patient is eligible for a referral to Cardiology Night. Confirm Referral: Cardiology
Request Out of Network Appointment
Cancel
Confirm Referral: Cardiology
Request Out of Network Appointment
Cancel
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)?
Criteria include one or more of the following:Â
intermittent or potential atrial fibrillation palpitations premature ventricular contractions tachycardia bradycardia Yes
No
Is the patient interested in using a Kardia Mobile Device? Yes
No
Smartphone Compatibility 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. Who to Refer: Any patient under the age of 18 seeking psychiatric services, including history or concern for the following:Â Depression & Anxiety Bipolar Disorder PTSD Schizophrenia and other psychotic disorders Personality disorders Other commonly treated psychiatric disorders Any child or adolescent who feels they may benefit from seeing a mental health professional We cannot prescribe controlled substances, including stimulants, benzodiazepines, and opioids. ***If a patient is acutely suicidal, homicidal, manic, and/or psychotic - please call 911 or direct patient to the nearest ED or mental health facility at the discretion of the attending physician***
Services offered: Diagnosis and management of mood, psychotic, and anxiety disorders outside of the scope of a primary care provider. Referrals to EACN Free Therapy Night. Clinic Times & Locations: When: 4th Tuesday of each month at 5:30pm Where: Eastside Clinic, 410 NE Waldo Road, Gainesville Appointments are required I acknowledge that common psychiatric concerns, such as stable depression or anxiety, are typically managed in the primary care setting. This includes medication refills for stable patients and initiation of medications.
* must provide value
Confirm
Cancel referral, patient will be managed by Primary Care
Confirm
Cancel referral, patient will be managed by Primary Care
Reason for Child Psychiatry Referral? *We cannot prescribed any controlled substances, including stimulants, benzodiazepines, or opioids *
* must provide value
Reason for Child Psychiatry Referral? Please include a ny known psychiatric diagnoses and reason for referral
Any current psychiatric medications? Please include a ny current psychiatric medications and indication
PHQ-9A Score (Required ) Please upload the child's completed PHQ-9A to the 'Media' tab on Epic.
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
SCARED Score (Required ) Please upload the child's completed Screen for Child Anxiety Related Disorders (SCARED) to the 'Media' tab on Epic.
* must provide value
Confirm, uploaded into patient chart
Cancel Referral
Confirm, uploaded into patient chart
Cancel Referral
Your patient is eligible for a referral to Child Psychiatry.
Confirm Referral: Child Psychiatry
Cancel
Confirm Referral: Child Psychiatry
Cancel
Thank you! We have all the information we need for a Child Psychi atryReferral and our Psychiatry  team will follow up with the patient. Who to Refer: Patients with diabetes who have either been recently diagnosed or could benefit from additional education regarding the disease and how to manage it. After patients attend one class, they may be eligible to receive a prescription from EACN for a free Services offered: Education regarding: general risk factors, s igns/symptoms, treatment and prevention, and complications of diabetes How to read nutrition facts panel Different food groups and healthy options to choose from Exercise recommendations Online ADA resources Q&A session Clinic Times & Location: When: 2nd & 4th Thursday of each month, 5:00pm - 6:00pm Where: Main Street Clinic Both Walk-Ins and Appointments are accepted Would the patient like to request an appointment?
Confirm: Diabetes Education
Cancel
Confirm: Diabetes Education
Cancel
2nd Thursday
4th Thursday
Either
2nd Thursday
4th Thursday
Either
Thank you! We have all the information we need for a Diabetes Education Referral. Is this a referral for routine dental care or urgent dental needs?
* must provide value
Routine
Non-Urgent
Urgent
Select the appropriate dental treatment type:
* must provide value
Who to Refer: Patients without insurance who are pregnant and in need of regular prenatal care.
Services offered: Routine prenatal care through the 2nd trimester Genetic screening Assistance with medicaid/financial assistance applications Appointment Process: ***DO NOT GIVE PATIENT DATE OF APPOINTMENT*** If there are any concerns or questions in clinic, please contact Prenatal Call phone at 352-284-9921 Prenatal team will contact patient within one week of referral to conduct further screening Patient is welcome to contact Prenatal Call phone at 352-284-9921 M-F 7:00am - 5:00pm with questions Clinic Times & Location: When: Check EACN Calendar for next date Where: Main Street Clinic Appointments REQUIRED
Today M-D-Y
Patient's preferred language:
* must provide value
English
Spanish
Other
First day of most recent menstrual period:
* must provide value
Today M-D-Y
Gravidity (total # of pregnancies) Term (# of pregnancies > 37 weeks) Preterm (# of pregnancies > 20 weeks & < 37 weeks) Abortion (# of abortions/miscarriages < 20 weeks) Living (# of living children)
Gravidity (total number of pregnancies)
* must provide value
Term Pregnancies
* must provide value
Preterm
* must provide value
Abortion/Miscarriage
* must provide value
Living children
* must provide value
History of pregnancy complications? Please select all that apply:
Approximate gestational age of miscarriage:
Please list any additional prenatal complications:
Pre-pregnancy weight (lbs):
Your patient is eligible for a referral to Prenatal * must provide value
Confirm Referral: Prenatal
Cancel
Confirm Referral: Prenatal
Cancel
Thank you! We have all the information we need for a Prenatal ReferralPrenatal team will follow up with the patient. Who to Refer: Concern for actinic keratosis, BCC, SCC, Melanoma Poorly controlled psoriasis Hidradenitis suppurativa Servere, poorly managed skin conditions with unclear causes Services we DO NOT offer: Cosmetic procedures such as Botox, filler, female-pattern or male-pattern hair loss, cherry hemangiomas, skin tags, spider veins, vitiligo, melasma, post inflammatory hyper or hypopigmentation, asymptomatic tinea versicolor, non-irritated seborrheic keratosis, lipomas, pilonidal cysts, etc. Management of atopic dermatitis with no attempt with corticosteroids Full body skin exams Patient MUST currently have a lesion that you are concerned about being cancerous OR have had biopsy-proven skin cancer diagnosed within the last year Management of acne that has not been managed topically first (benzoyl peroxide, topical clindamycin, OTC retinoid, OCPs) Clinic Times & Locations: When: 2nd Tuesday of each month Where: Eastside Clinic, 410 NE Waldo Road, Gainesville Appointments are REQUIRED . Please keep in mind there is a long waitlist for Dermatology services. Reason for Dermatology referral?
* must provide value
Concern for actinic keratosis, BCC, SCC, or melanoma
Hidradenitis suppurativa
Poorly controlled psoriasis
Severe and poorly managed skin conditions with unclear causes
Other
Concern for actinic keratosis, BCC, SCC, or melanoma
Hidradenitis suppurativa
Poorly controlled psoriasis
Severe and poorly managed skin conditions with unclear causes
Other
Please provide additional information regarding Dermatology referral * must provide value
Lesion Picture Please take a photo of EACH skin lesion and upload to the patient's chart (documents section of PF homepage).
You MUST place the name of the body area being photographed in the title of the photo (i.e. "Derm Referral R Leg")
Please note this is required for management of a skin lesion.
* must provide value
Picture uploaded and labeled with the body area of the photo(s)
Picture not uploaded
Picture Not Applicable in this case
Picture uploaded and labeled with the body area of the photo(s)
Picture not uploaded
Picture Not Applicable in this case
STOPÂ An image must be uploaded to the patient's chart prior to being referred to the Dermatology Clinic as this is required for triage. If an image was not uploaded and the patient has left, please coordinate with the clinic officers and/or patient to have images uploaded prior to being triaged by Dermatology.
Your patient is eligible for a referral to Dermatology Night.
* must provide value
Confirm Referral: Dermatology
Cancel
Confirm Referral: Dermatology
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 inform the patient that there is a lengthy wait list for Dermatology appointments, if their referral is approved.Â
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 offer pap smears (Eastside and Main Street) on any night. Gynecology Night spots should be reserved for patients who specifically need the expertise of an OBGYN.
Services offered: Advanced gynecologic evaluation beyond what a PCP can handle IUD insertion or removal Depo-Provera contraception Mammogram follow-up Nexplanon insertion or removal Clinic Times & Locations: When: 1st Thursday of every month Where: Main Street Clinic Appointments preferred, Walk-Ins not guarenteed Reason for Gynecology referral?
Any additional information for Gynecology referral?
Your patient is eligible for a referral to Gynecology Night.
Confirm Referral: Gynecology Night
Cancel
Confirm Referral: Gynecology Night
Cancel
Pap smears (and other general women's health) are provided at our Eastside & Main Street primary care clinics. Patients requiring a routine pap are NOT eligible for a referral to Gynecology Night. Thank you!Â
Referrals for Mammograms can be completed by Primary Care Clinics and do not require an appointment with Gynecology . Please select "Order Imaging" above to refer your patient for a mammogram. Thank you!Â
Thank you! We have all the information we need for this patient's Gynecology ReferralGynecology team will follow up with the patient. Who to Refer: Any patient who identifies as LGBTQ
Services offered: Gender-affirming therapy for patients ages 18+ PrEP for HIV prevention Primary care in an accepting environment Clinic Times & Locations: When: 1st & 3rd Tuesday of every month Where: Eastside Clinic, 410 NE Waldo Road, Gainesville. Appointments preferred, Walk-ins not guarenteed
Reason for Community Clinic referral? General Services
Hormone Therapy
General Services
Hormone Therapy
Hormone Therapy Patients Type of Therapy Requested:
Masculinization
Feminization
Masculinization
Feminization
Hormone Therapy Patients
We do need lab results to be able to begin HRT. These labs take ~1 week 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.
Please ask a clinic officer to order (using the LGBT night order panel):Â
CBC without diff Estradiol Total Testosterone Serum albumin Please ask a clinic officer to order (using the LGBT night order panel):
Estradiol Total Testosterone BMP Any additional information regarding Community Clinic  referral?
Your patient is eligible for a referral to Community Clinic at Eastside .
* must provide value
Confirm Referral: Community Clinic at Eastside
Walk In
Cancel Referral
Confirm Referral: Community Clinic at Eastside
Walk In
Cancel Referral
Thank you! We have all the information we need for this patient's Community Clinic Referral . Our Community Clinic  team will follow up with the patient. Who to Refer: Patients with any of the following conditions falling outside the scope of a primary care provider:
Resistant hypertension Long-standing hyptertension or diabetes with evidence of end-organ damage Unexplained reduced renal function/chronic kidney disease or electrolyte abnormalities Pre-existing CKD with eGFR <30 for >3 months Recurrent known kidney stones Services offered: Nutrition consults Point of care renal ultrasound to assess kidney function Patient education and lifestyle modifications on the disease processes noted above Clinic Times & Locations: When: Monday nights approximately every other month (Officers will contact the patient with specific dates) Where: Seventh Day Clinic, 12909 NW 39th Ave, Gainesville Appointments preferred, Walk-ins not guaranteed  Reason for Nephrology referral:
Uncontrolled hypertension
Uncontrolled diabetes
History of/Concern for Chronic Kidney Disease
Electrolyte abnormalities
Worsening kidney function
Other
Uncontrolled hypertension
Uncontrolled diabetes
History of/Concern for Chronic Kidney Disease
Electrolyte abnormalities
Worsening kidney function
Other
Please specify why you're referring this patient to Nephrology Night:
Your patient is eligible for a referral to Nephrology Night.
Confirm Referral: Nephrology
Cancel
Confirm Referral: Nephrology
Cancel
Thank you! We have all the information we need for a Nephrology ReferralNephrology team will follow up with the patient. Who to Refer: Adults who are uninsured or cannot otherwise afford psychotherapy Anyone in need of mental health counseling for depression, anxiety, post-traumatic stress, insomnia, substance use, family/relationship/occupational stress, etc. Services offered: Mental health counseling for a wide variety of concerns One 30-minute initial consultation & up to five 50-minute therapy sessions Clinic Times & Locations: When: Every Monday from 5:30pm - 7:30pm Where: Via Zoom/Phone Appointments preferred, Walk-ins not guarenteed 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 24/7, 365 days a year)
Appointments :
New Clients (first time or >6 months since last seen): (352) 374-5600, option 2 Returning Clients: (352) 374-5600, option 3 Reason for Free Therapy Night Referral:
Your patient is eligible for a referral to Free Therapy Night.
Confirm Referral: Therapy Night
Cancel
Confirm Referral: Therapy Night
Cancel
Thank you! We have all the information we need for a Free Therapy Night  ReferralFree Therapy Night  team will follow up with the patient. Who to Refer: Patients who have had more than 1 fall in the last 3 months. Patients who have trouble doing everyday activities such as cooking, cleaning, dressing, showering, feeding, etc. Patients who often forget to take medications, attend appointments, and have trouble managing their health/healthcare on their own. Any patient who feels they may benefit from working with an Occupational Therapist. Services offered: Free Occuptation Therapy services to people unable to afford treatment elsewhere. OT evaluation, treatment, follow-up, screenings for blood pressure and strength/flexibility, and referrals to specialists as needed. OT services for those with recent injuries or surgeries, and even preventative care for those who may benefit. Clinic Times & Locations: When: Thursday evenings from 6:00PM - 8:00PM Where: Smart House in Oak Hammock on Williston Road Appointments are required Follow this link for referral submission (opens in a new window)! Reason for Occupational Therapy  Referral:
Who to Refer: Adults with significant vision loss , diabetics who have not been connected to eye care, and patients with a history of glaucoma .
We do NOT see pediatric patients or patients in need of glasses/contact lenses without other significant ophthalmologic concerns.
Services offered: C omplete Exam s: IOP (interocular pressure) measurements, slit lamp exams, dilated fundus examsScreening: for cataracts, diabetic eye disease, glaucoma, retinal diseaseWork-up: for acute eye problems (pain, vision change, trauma, etc)Referral: to WeCare, Shands Charity CareWe do NOT offer refractions for glasses or contact lenses. Clinic Times & Locations: When : Last Tuesday of each month at 5:00pm Where: HealthStreet at 2401 SE Archer Rd, Gainesville, FL 32608 Does the patient have insurance?
Yes
No
Does the patient have diabetes AND an A1C > 7.5?
Yes
No
Does the patient have a family history of glaucoma?
Yes
No
Has the 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 Night.
* must provide value
Confirm Referral: Ophthalmology
Cancel
Confirm Referral: Ophthalmology
Cancel
Thank you! We have all the information we need for an Ophthalmology Referral and our Ophthalmology team will follow up with the patient. Unfortunately, this patient does not qualify to be seen at our Ophthalmology Clinic. Please see an officer if you feel that the patient could still be eligible for a referral to Ophthalmology . They may enter an override password below if needed.Â
Â
Options for patients to receive eyeglasses and/or vision exams at no or low cost are listed below:
Alachua Department of Social Services
Provides vision exams and eyeglasses at low costs Where: 218 SE 24th Street, Gainesville, FL 32641. Phone number: (352) 264-6750 When: Monday-Friday from 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 Where : 238 SW 4th Ave, Gainesville, FL 32601. Phone number: (352) 372-8162When: Monday-Thursday from 9:00am-2:30pm Eligibility: For uninsured Alachua County residents with no/low income Helping Hands Clinic
Provides referrals for eye exams and used/refurbished eyeglasses for the homeless. Where: 509 NE 1st Street, Gainesville, FL 32601. Phone number: (352) 519-5542 When: Monday Nights from 4:30pm-7:00pm Eligibility: Must be homeless and/or below a certain income level. Officer Override
Disclaimer
Reason for Pediatric Ophthamology Referral:
* must provide value
Your patient is eligible for a referral to Pediatric Ophthalmology.
* must provide value
Confirm Referral: Peds Ophtho
Cancel
Confirm Referral: Peds Ophtho
Cancel
Thank you! We have all the information we need for a Pediatric Ophthalmology Referral and our Ophthalmology team will follow up with the patient. Who to Refer: Any pediatric patient in need of medical care!
Services offered: Well-child check-ups School physicals Sport physicals Sick child visits Clinic Times & Location: When : The 1st & 4th Wednesday of each month at 5:30pm Where : Bartley Temple Clinic, 1936 NE 8th Ave, Gainesville, FL 32641 Who to Refer:Â Individuals seeking Physical Therapy services with orthopedic, cardio-pulmonary, and neurological diagnoses, especially those with limited insurance coverage. We treat everyone in need of therapy care including: recent injury, postsurgical, preventative care, etc.
Services offered: Physical Therapy services to people unable to afford treatment elsewhere. Evaluation and treatment, follow-up treatment visits, blood pressure and strength/flexibility screenings, referrals to specialists, and emergency medical referrals. We CANNOT treat pediatric patients. Clinic Times & Location: When: Every Thursday evening from 5:00PM - 8:00PM W here: The CVS located at 1621 SW 13th Street, Gainesville Referral Form (required if paper copy not submitter via referrals officer):
PT Referral form (updated)Â
Who to Refer: Patients with a history of or concern for the following:
Depression/Anxiety Bipolar disorder PTSD Schizophrenia & other psychotic disorders Personality disorders Other commonly treated psychiatric disorders We cannot prescribe stimulants for ADHD treatment ***If a patient is acutely suicidal, homicidal, manic, and/or psychotic - please call 911 or direct patient to the nearest ED or mental health facility at the discretion of the attending physician***
Services offered: Psychiatric services that cannot be handled by a primary care provider. Initiation of psychiatric medications (Excluding any controlled substances ). Diagnosis and management of any of the conditions listed above. Clinic Times & Locations: When/Where:
4th Tuesday of each month @ Eastside Clinic 3rd Monday of each month @ Main Street Clinic Appointments are required I acknowledge that common psychiatric concerns, such as stable depression or anxiety, are typically managed in the primary care setting. This includes medication refills for stable patients and initiation of medications.Â
*Referral to Psychiatry is generally reserved for cases that are complex, severe, or non-responsive to initial treatment
* must provide value
Confirm
Cancel referral, patient will be managed by Primary Care
Confirm
Cancel referral, patient will be managed by Primary Care
Reason for Psychiatry Referral? *We cannot prescribed any controlled substances, including stimulants, benzodiazepines, or opioids *
* must provide value
Any additional information for Psychiatry Referral? Please include any known psychiatric diagnoses.
Any current psychiatric medications?
PHQ-9 Score (required ) Please upload the patient's completed PHQ-9 to the 'Media' tab on Epic.
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
GAD-7 Score (required ) Please upload the patient's completed GAD-7 to the 'Media' tab on Epic.
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Your patient is eligible for a referral to Psychiatry.
* must provide value
Confirm Referral: Psychiatry
Cancel
Confirm Referral: Psychiatry
Cancel
Thank you! We have all the information we need for a Psychiatry Referral and our Psychiatry  team will follow up with the patient. Who to Refer: Patients who are having concerns with:
food or housing insecurity child or elder care immigration services legal services finding/maintaining work intimate partner violence computer literacy variety of other social situations Services offered: Patients are offered a 20 minute appointment with a Social Worker to discuss their social needs and are provided resources to independently follow-up on. Clinic Times & Locations: When/Where:
2nd Thursday of the month @ Main Street Clinic 1st Tuesday of the month @ Eastside Clinic *Other options may be available depending on Social Worker Availability* Reason for Social Work Referral? Please check all that apply.
* must provide value
Any additional information for Social Work Referral? Including more details allows us to better tailor our services to the patient's needs!Â
* must provide value
When and how does the patient prefer to be contacted?
If the patient is looking for mental health counseling services, please refer the patient to Free Therapy Night (see Referrals menu) to be referred for free counseling.
Patient's location preference?
Language What is the patient's preferred language?
English
Spanish
Other
If a patient speaks a language other than English or Spanish, please list here:
Is this referral to Social Work for guidance with Patient Financial Assistance Program eligibility?
Yes
No
Unknown
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
Thank you! We have all the information we need for a Social Work Social Work team will follow up with the patient.
See our pharmacy team to place a referral.
Please indicate urgency of referral:
Routine
Urgent
Please indicate the ultrasound 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 of Ultrasound?
Left
Right
Bilateral
Location of Soft Tissue Ultrasound ?
* must provide value
Reason for Ultrasound Imaging ?
* 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. May have water, diabetics may have juice.
Younger than 10 yrs old:Â Â Â Newborn - 4m: 2-3h NPO Â Â 4m - 1 year: 4h NPO Â Â 1 year - 6 year: 6h NPO
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 verify the patient's address in Epic as this is used to determine the location of the clinic bus for radiology night. Verified & Correct
Unknown
Verified & Correct
Unknown
Your patient is eligible for a referral to for radiology services.
* must provide value
Confirm Referral: Radiology
Cancel
Confirm Referral: Radiology
Cancel
Thank you! We have all the information we need to schedule the patient for their radiology service. Is the patient between the ages of 40 and 64?
Yes
No
Screening Mammogram Instructions Completed through the Florida Breast and Cervical Cancer Early Detection Program (FBCCED) through Project CONTINUITY.
Ask an officer for a printed form and fill it out with a patient.
Counsel patient Let the patient know they should receive a call from Project CONTINUITY in 1-2 weeks. If they do not receive a call, please advise the patient to call them at (352) 359-5184 or call the EAC office at (352) 273-9425.
Confirm that you or a clinic officer has filled out the Project CONTINUITY paperwork.Â
Officers should upload the referral packet to the patient's chart.
Paperwork completed
Cancel referral
Paperwork completed
Cancel referral
Thank you for referring your patient for a screening mammogram .
Gynecology officers will follow-up with the patient regarding the results.Â
Confirm mammogram ordered
Cancel
Confirm mammogram ordered
Cancel
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.
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
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
Diagnostic
Screening
Yes
No
WeCare Eligible 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
Once you have spoken to the officer and completed We Care paperwork, please look at the second line of the patient referral form for the box which indicates "urgency of referral" and indicate this here. This information is used to confirm with We Care staff that the patient's eligibility appointment has been completed.
Routine
Urgent
Expedite
UF Health Financial Assistance Program Eligible Confirm UF FAP Referral
Cancel
Confirm UF FAP Referral
Cancel
UF Health Financial Assistance Program Officer Instructions Patient Eligibility Â
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). Â
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.Â
Â
UF Health FAP Application Financial assistance applications and information are available in English, Spanish, and Financial Assistance | UF Health
UF Health Financial Counselors are available at 352-265-0355 or toll free at 800-342-5364.
Â
In addition, financial assistance applications can be picked up free of charge at the following locations:(updated 2-23-2022)
UF Health Shands Admissions Department Â
Patient Financial Services Â
Health Shands Cancer Hospital Â
UF Health Heart & Vascular and Neuromedicine Hospitals Â
UF Health Shands at Vista Â
Patients eligible for financial assistance at UF Health Shands will not be charged more for emergency or medically necessary care than amounts generally billed (AGB) to patients having insurance under Medicare.
Â
In Clinic Orders Please select any labs/orders completed in clinic tonight.
Do not select orders that were sent to Quest.Â
A1C & POC 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.Â
Order FIT Test: You can pick up a FIT testing kit from a clinic officer.FIT Testing is completed through Project Continuity Please fill out THIS FORM to ensure the patient's test is registered.
Form Completed: FIT Testing Ordered
Cancel
Form Completed: FIT Testing Ordered
Cancel
EKG/HIV/Pregnancy/Strep/Urinalysis: Please 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
Unsure
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
No
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
No
STOPÂ
Please check with the clinic officers to ensure that the this step is completed to ensure patient safety!
Thank you for documenting this patient's pap smear
Lab Specimen Select all that apply.
Lab Specimen Describe if needed
Patient Identifiers Are at least two different patient identifiers (name, PRN, birth date) written directly on the specimen bottle?
* must provide value
Yes
No
Lab Order Form Was the lab order form printed and included in the specimen bag?
* must provide value
Yes
No
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
STOPÂ
Please check with the clinic officers to ensure that the this step is completed to ensure patient safety!
Clinic Protocols Please select anything relevant for your patient from their clinic visit tonight.
Additional Eastside Options
 If you are even thinking about a Baker Act, Â
 please see an officer immediately.  Â
Leave this option checked upon submitting if a Baker Act was submitted.
A C linic Director needs to notified immediately if you are implementing this protocol.Â
Â
Overview of Protocol 1 . Medical student or undergraduate student IMMEDIATELY notifies site officer or attending.Â
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. Ask them to stay but do not attempt to physically restrain the patient if they decide to leave.
2 . 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 .
3. Attending expresses concern about patient and offers them voluntary commitment.
4. Patient refuses voluntary commitment.
5. Attending completes Baker Act Form -->Â see below to determine where GPD should transport pt
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.
6. Photo copy Baker Form, upload to PF chart after faxing it as above, and provide original to GP
7. Police arrive and form goes with patient and police
8. Document
Â
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. Sources used include:Â 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.
Type of Records Requested What records are you hoping to obtain for this patient?
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.
Please select the following risk factors your patient has: See above (risk factors section)
* must provide value
Positive
Negative
Patient Renal Function (eGFR) * must provide value
Positive
Negative
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 the following:
4th generation HIV test serum Creatinine hepatitis serologies (using order panel) 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.
We typically order labs at each visit for the follow-up visit.
Has the patient had PrEP prescribed with EACN before?
Yes
No
Date last labs were drawn * must provide value
Today M-D-Y
Positive
Negative
Positive
Negative
Positive
Negative
Positive
Negative
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.
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
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 Gynecology Night for this service, please uncheck the LARC option.
Copper IUD
Depo-Provera Injection
Mirena IUD
Nexplanon
Copper IUD
Depo-Provera Injection
Mirena IUD
Nexplanon
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 the patient use tobacco products? * must provide value
Yes
No
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:
Please specify other substances: * must provide value
Mental Health History Please select any prior mental health diagnosis patient endorses.
Please specify other psychiatric diagnoses: * must provide value
PHQ-9 Score: Please enter the patient's PHQ-9 score from this visit (if indicated).
Please select the type of Gender Affirming Therapy visit desired: 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.
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 Serum Estradiol (not total estradiol) Serum Total Testosterone LC/MS/MS Serum Albumin These labs should be completed at least one full week prior to next clinic visit.Â
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 be completed at least one full week prior to next clinic visit.Â
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 recommend giving the form to the patient to review and return at the initiation of therapy visit.
It must be signed and scanned into the patient's chart 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 informed consent form was uploaded to patient's chart.
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.
* 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
Masculinization Therapy Please select the medication and dose prescribed today.
Testosterone Cypionate 50mg once weekly
Testosterone Cypionate 50mg twice weekly
Other
Testosterone Cypionate 50mg once 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
Please specify the medication, dose, and frequency prescribed today.
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?
Please specify the reason the patient has stopped recieving care from us.
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
General Patient
Spanish-Night Patient
Prenatal Night Patient
General Patient
Spanish-Night Patient
Prenatal Night Patient
Social Work should be selected only if the patient was seen by a Social Worker tonight, not simply referred to Social Work.Â
Adult Patient
Pediatric Patient
Adult Patient
Pediatric Patient
General Patient
Gynecology Night Patient
Social Work Patient
Cardiology Patient
General Patient
Gynecology Night Patient
Social Work Patient
Cardiology Patient
Social Work should be selected only if the patient was seen by a Social Worker tonight, not simply referred to Social Work.Â
Date of Clinic * must provide value
Today M-D-Y
Resident: (If a resident was involved in this patient's care)
Example: Robert Case, MD
Attending: Example: Ryan Nall, MD
* must provide value
Review Patient and Volunteer Information Patient : ______ ______ ______ ______
Medical Student Volunteer : ______ (______ )Â blank if seen by Officer
EACN Officer Contact : ______ (______ )
Â
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: ______ Community Clinic: ______ Free Therapy Night: ______ Ophthalmology: ______ Peds Ophthalmology: ______ Physical Therapy: ______ Prenatal: ______ Social Work: ______ Radiology: ______ ______
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
______
______
You will receive  a confirmation email and copy of each referral .
Officer Approved An officer must sign off on this form prior to submission * 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
   READY FOR SUBMISSION   Please press submit to finalize your submission.
Please contact an officer if you need to make changes to anything you previously submitted.
   DO NOT PRESS SUBMIT   Once you have finished placing referrals and have finished all tasks for your patient, bring to an officer for review and submission. This box will disappear when you are ready for submission.
Submit
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