Form Generator - Please do not edit
* must provide value
Disclaimer
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
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 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.
Does the caller want general information about COVID-19?
Please ensure caller is not asking about specific COVID-19 symptoms. Indicating 'No' will skip all COVID-19 screening questions.
Yes
No
Does this patient want to provide identifying information? If yes, please continue.
Yes
No
Nombre completo: Full Name * must provide value
Fecha de nacimiento: Date of Birth * must provide value
Today M-D-Y
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.
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
Anna Villagomez
Other
Laura Ramirez
Anna Villagomez
Other
Your Email (UFL Email is preferable) * must provide value
Today M-D-Y
¿Ha recibido alguna vez una vacuna COVID-19?
Yes
No
La vacuna COVID-19 lo ayudará a protegerse de contraer COVID-19. Es posible que tenga algunos efectos secundarios, que son signos normales de que su cuerpo está generando protección. Estos efectos secundarios pueden afectar su capacidad para realizar las actividades diarias, pero deberían desaparecer en unos días. ¿Ha experimentado algún efecto secundario relacionado con la vacuna?
Yes
No
¿Qué tipo de vacuna COVID-19 recibió?
Pfizer-BioNTech
Moderna
Johnson & Johnson / Janssen
Pfizer-BioNTech
Moderna
Johnson & Johnson / Janssen
¿Cuántas dosis de la vacuna COVID-19 ha recibido?
One dose
Two doses
¿Qué tipo de síntomas ha experimentado desde que recibió su vacuna COVID-19?
Si respondió "Otro", describa aquí los efectos secundarios específicos del paciente.
¿Ha tomado algún medicamento de venta libre, como ibuprofeno, acetaminofeno, aspirina o antihistamínicos para estos efectos secundarios?
Yes
No
¿Tomar estos medicamentos ayudó a aliviar sus síntomas?
Yes
No
¿Cuánto tiempo han durado estos síntomas después de recibir su última vacuna?
Less than 1 day ago
1-3 days ago
More than 3 days ago
Less than 1 day ago
1-3 days ago
More than 3 days ago
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
View equation
¿Cual fue el resultado?
* must provide value
Negativo
Positivo
¿En este momento, tiene usted síntomas de COVID-19?
Los síntomas pueden incluir: fiebre o escalofríos, tos, dificultad para respirar o dificultad para respirar, fatiga, dolores musculares o corporales, dolor de cabeza, nueva pérdida del gusto u olfato, dolor de garganta, congestión o secreción nasal, náuseas o vómitos, diarrea
Yes
No
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
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
Síntomas no severos:
Please check all that apply.
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
Sintomas sin confirmacion de COVID-19: ¿Tiene usted síntomas de COVID-19 aunque no se ha confirmado un diagnostico?
¿En las ultimas dos semanas, ha usted tenido contacto o exposición con una persona con coronavirus?
Yes
No
Describa el tipo de contacto
* must provide value
[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
Por favor incluya aquí la información o las razon(es) sobre un referido a un médico.
Include here information / the reason(s) for referral to a medical provider.
¿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]
¿Toma usted medicamentos para estas condiciones o otras condiciones medicas?
Yes
No
¿Cuales medicamentos?
* must provide value
¿Necessita rellanar sus medicaciones?
Yes
No
Yes
No
¿Necesita usted ayuda con asuntos que no son médicos? Por ejemplo:
Detailes de asuntos legales:
Si tiene otras necesidades, cuales son?
Would you like to refer the patient to medical monitoring or to emergency (911) for COVID-19 vaccine related side fx?
Medical monitoring
Emergency services (911)
Medical monitoring
Emergency services (911)
Please indicate which of the following you advised when counselling the patient on their COVID-19 vaccine related side effects.
Side effects after your second shot may be more intense than the ones you experienced after your first shot. These side effects are normal signs that your body is building protection and should go away within a few days. (Relevant for Pfizer and Moderna vaccines only)
Consider taking over-the-counter medicine, such as ibuprofen, acetaminophen, aspirin, or antihistamines, for any pain and discomfort you may experience after getting vaccinated. You can take these medications to relieve post-vaccination side effects if you have no other medical reasons that prevent you from taking these medications normally.
If redness/tenderness of vaccine site gets worse after 24 hours, call this number again.
If your side effects are worrying you or do not seem to be going away after a few days call this number, or, if necessary, emergency services
Side effects after your second shot may be more intense than the ones you experienced after your first shot. These side effects are normal signs that your body is building protection and should go away within a few days. (Relevant for Pfizer and Moderna vaccines only)
Consider taking over-the-counter medicine, such as ibuprofen, acetaminophen, aspirin, or antihistamines, for any pain and discomfort you may experience after getting vaccinated. You can take these medications to relieve post-vaccination side effects if you have no other medical reasons that prevent you from taking these medications normally.
If redness/tenderness of vaccine site gets worse after 24 hours, call this number again.
If your side effects are worrying you or do not seem to be going away after a few days call this number, or, if necessary, emergency services
Please provide call notes here:
* must provide value
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
Please confirm that you have either connected this patient with primary care provider or have contacted physicians through What's App for medical advice.
Confirm
Cancel
Please call 911 to refer this patient to emergency services.
Add the patient to our followup worksheet.
* must provide value
Confirm
Cancel
Please confirm that the patient is being referred to medical monitoring.
Add the patient to our monitoring worksheet.
* must provide value
Confirm
Cancel
Basándose en elegibilidad, podemos ofrecer los siguientes recursos:Prueba de COVID-19: Unchecked Observación medica por el periodo de cuarentena: ______ Medicamentos: ______ Cuidado medico a largo plazo: ______ - If yes, details: ______
Vaccine side fx action: [cov_vac_sidefx(1)] - If yes, details: ______
Ayuda con la nutricion: Unchecked Ayuda financeria: Unchecked Ayuda con asuntos legales: Unchecked Otras necesidades: ______
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
Spanish 7th Day Clinic
Anthem Church
Eastside Clinic
Bartley Temple
Main Street Clinic
Derm Clinic
Other
Spanish 7th Day Clinic
Anthem Church
Eastside Clinic
Bartley Temple
Main Street Clinic
Derm Clinic
Other
Please indicate name of site:
e.g. "MOC" for Mobile Outreach Clinic
What is your role? * must provide value
Medical Student Volunteer
Medical Student Officer
HOQI Intern
Research Volunteer
Outside Referral
Derm Clinic Volunteer
Medical Student Volunteer
Medical Student Officer
HOQI Intern
Research Volunteer
Outside Referral
Derm Clinic Volunteer
Officer Password
* must provide value
Disclaimer
Submit Password
Disclaimer
Officer Mode
Welcome ______ to Officer Mode!
You can use the options listed here to quickly access clinic forms and submission instructions.
Clinic Admin
Please select anything relevant for your patient and you will be provided with more information once you scroll down.
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
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
3) Patient PRN * must provide value
4) Patient Number As shown on the clinic tracker, should autofill, number 1-25.
* must provide value
Please select a research study:
Prenatal care survey
None of the above
Prenatal care survey
None of the above
Research Study Mode Alert: Research Mode will allow you to submit without entering patient information (ie to contact directors). If you are submitting a study record, be sure to select "Enter Patient Information" here. Enter Patient Information
No Patient Information Required for Submission
Enter Patient Information
No Patient Information Required for Submission
If you are pregnant/were to be pregnant do you have somewhere to go for prenatal care? // ¿Si Ud.
está embarazada/si Ud. estuviera embarazada, tiene/tendría algún lugar donde puede/pueda
recibir su cuidado prenatal?
Yes // Sí
No // No
If EAC were to start offering prenatal care, would you be interested in obtaining your care
here? // ¿Si EAC empezara a ofrecer servicios de cuidado prenatal, Ud. estaría interesada en
recibir su cuidado médico con nosotros?
Yes // Sí
No // No
Do you know anyone who would be interested in obtaining their prenatal care at EAC? // ¿Ud conoce alguien que estaría interesada en recibir su cuidado prenatal con nosotros?
* must provide value
Yes // Sí
No // No
If you marked "yes" to the above question, we're now transitioning to a question for clinic use:
Would you please provide the full name and contact information for the person you wish to refer?
Outside Referral Mode Alert: Outside Referral Mode will allow you to refer a patient to one of our primary care or specialty clinics. * 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
Date of Referral
* must provide value
Today M-D-Y
(HIDDEN) Was the patient screened today at clinic? * must provide value
Yes
No
If no, please screen for COVID-19 as soon as possible, before continuing.
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
Yes
No
Female
Male
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) 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
9a) Family history of colon cancer? If unsure, leave blank.
Yes
No
9b) Age of family member at CRC diagnosis If unsure, leave blank.
10) 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
AAA Screening needed? One-time abdominal ultrasound indicated.
* must provide value
Yes
No
Diabetes screening needed? Abnormal blood glucose screen is indicated.
Yes
No
Mammogram needed? Screening mammogram is indicated every 2 years after the age of 40. If you select YES, please make sure to check the box for "Gynecology" under "Referrals." The patient will receive mammography services through Gynecology Night.
* 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? 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 who have not been screened in the past year 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
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
Screened positive for intimate partner violence? ALL patients must be screened for intimate partner violence at EACH visit. Please ask 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?"
If your patient responds "yes" to any of these questions, please mark "yes" in this field.
* 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
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
Today M-D-Y
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
Today M-D-Y
Today M-D-Y
Today M-D-Y
Handoff
(HIDDEN) Please refer to the handoff sheet the undergraduate HOQI volunteer provided you and select the "Intake Screening Questions" they checked.
Handoff (HIDDEN) Please review the handoff form the undergraduate HOQI volunteer provided you (or emailed you) and check the corresponding box for the referral(s) and/or test(s) indicated for your patient.
Place Orders
You can select all the relevant orders and complete them in one submission.
Please select any labs you order: Lipid panel = ______
Pap and HPV = ______
* must provide value
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 = ______
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
Note: Please speak to an officer if the ONLY reason you are placing a referral is for the completion of an EKG. Some clinic sites are able to perform EKGs in-clinic.
* 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
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 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
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.
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
Equal Access Clinic Prenatal Night Who to Refer: Patients without insurance who are pregnant and in need of regular prenatal care.
Services offered at no cost to patient: -Routine prenatal care -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 0700-1700 with questions
Clinic Location and Times: - Main Street Family Medicine Clinic. Check EACN Calendar for next date. - Appointments REQUIRED
Patient's name:
* must provide value
Date of Birth:
* must provide value
Today M-D-Y
Patient's address:
* must provide value
Patient's phone number:
* must provide value
Patient's preferred language:
* must provide value
English
Spanish
Other
Patient's name, contact information (address, phone number), and preferred language:
First day of last menstrual period:
* must provide value
Today M-D-Y
Gravid/ parity status?
How many total pregnancies?
Full-term births?
Pre-term births?
Miscarriages/ abortions?
Living children?
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
Method of delivery:
* must provide value
History of pregnancy complications?
History of pregnancy complications
Please select all that apply:
Approximate gestational age of miscarriage:
Please list any additional prenatal complications:
Your patient is eligible for a referral to prenatal night.
* must provide value
Confirm Appointment: Prenatal
Cancel
Confirm Appointment: Prenatal
Cancel
Thank you! We have all the information we need for a prenatal referral and our prenatal 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 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 (documents section of 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
STOP An image must be uploaded to the patient's chart prior to being referred to the Dermatology Clinic.
If an image cannot be captured or is not applicable, please provide an explanation as to why no image is uploaded.
* must provide value
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 Gynecology Night
Who to Refer:
Patients who require gynecologic care beyond what a primary care physician can handle as well as ANY patient in need of a screening mammogram. 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 Gynecology 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
- IUD insertion / removal
- Depo Provera contraception
- Mammogram
Clinic Location and Times:
- Main Street Clinic on the First Thursday of every month
- Appointments preferred, Walk-Ins are accepted
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.
(HIDDEN)
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.
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.
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.
Would you like to refer the patient to social work?
Yes
No
Who to Refer: Please utilize the screening questions below to identify who could benefit from an OT referral. Have you had more than 1 fall in the last 3 months? Are you tired while doing everyday activities? Ex: showering, dressing, cooking, etc. Is it hard to complete everyday activities by yourself because of decreased balance, difficulty moving your body, or weakness? Ex: getting dressed, brushing teeth, driving, cooking, cleaning, showering, eating/feeding, etc. Is it hard to safely lift a pot of water? Is it hard getting around your home or using the bathroom by yourself? Do you often forget to take your medication? Is it hard to start or keep a healthy schedule or routine? Are you easily distracted or needing extra reminders to complete your daily tasks? Is it hard to fall asleep, stay asleep, or feel rested throughout your day? Is it hard to engage in activities that are important to you? Have you had any major changes in your life roles within the past 6 months? Ex: new parent, newly retired, new caregiver, etc. 11b. If yes to the above question (#11), is it hard to manage daily tasks and schedules?If a patient answers "Yes" to 2 or more of the above questions, they would benefit from occupational therapy services.
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
Follow this link for referral submission (opens in a new window)! (HIDDEN) 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
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 this PT Referral form (updated) to request a patient appointment. The patient may also fill this form out on their own behalf.
Patient Reminder
Should our undergraduate team contact the patient to remind them about PT clinic? Contact Patient
Cancel
NEW - EACN Psychiatry
We are able to diagnose and treat: - Depression and anxiety following first-line management with SSRI/SNRI - Bipolar disorder - PTSD - Schizophrenia and other psychotic conditions IF patient is not acutely psychotic - Personality disorders with conduct disturbance - Other common psychiatric conditions for patients who are not acutely suicidal, homicidal, manic, and/or psychoticWe 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*** For any questions, please call Alyssa Nielsen, MS4 at (850) 619 – 8549 in clinic or email at alyniel@ufl.edu if a non-emergent question arises
Other Community Resources:
Referral Information Please include: - Reason for referral - Any known psychiatric history - Any current psychiatric medications - PHQ9, GAD7, and mood disorder questionnaires (submit scores here and upload full copy into Practice Fusion. Copies of these questionnaires are available on the volunteer and officer manuals)
Currently, EACN's Rheumatology clinic is not in operation. They will require outside referral (likely WeCare) to the community.
Please order the following initial labs for the patient: 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 (2nd Thursday of the month)
- EAC Eastside (1st Tuesday of the month) Which location would the patient like to attend?
*Currently, EAC Social Work is only offered on the 2nd Thursday of the month at Main Street and the 1st Tuesday of the month at Eastside.
Please briefly describe the patient's need for referral.
* must provide value
Please briefly describe "Other" indication;
If multiple reasons, please mark as many as possible in the above checkboxes then separate each additional reason with a semicolon.
(HIDDEN)
* must provide value
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
How urgent is this request?
Routine
Urgent
(HIDDEN)
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.
Your patient is eligible for an appointment with EACN 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) = ______
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
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.Referrals can ONLY be placed through the clinic navigator. DO NOT contact MOC directly about your patient. Please select SUBMIT at the bottom of the page if you are finished.
Which type of screening imaging would you like to order?
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.
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
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
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
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.
Urgency of referral to We Care:
Routine
Urgent
Expedite
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 Financial assistance applications and information are available in English, Spanish, and Mandarin: Financial Assistance | UF Health
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:(updated 2-23-2022)
UF Health Shands Admissions Department 1600 SW Archer Rd Room 1331, or 1335-1 Gainesville, Fl 32608
Patient Financial Services 3300 SW Williston Rd. Gainesville, Fl 32608
Health Shands Cancer Hospital Admissions Department, Room 1319 1515 SW Archer Road Gainesville, FL 32608
UF Health Heart & Vascular and Neuromedicine Hospitals Cashier’s Office, Room 1522 1505 SW Archer Road Gainesville, FL 32608
UF Health Shands at Vista Admissions Department, Room 1105.5 4101 NW 89th Boulevard Gainesville, FL 32606
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.
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/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 filled out via Qualtrics (updated 12/6/23).
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.
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.
Additional Eastside Options
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
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 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
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 (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
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
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
Select any prior mental health diagnosis patient endorses
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?
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.
Does the patient plan to get a COVID-19 vaccine when it becomes available to them? Yes
No
Already vaccinated/already scheduled for vaccine appointment
N/A (please select only if you did not see a patient in clinic tonight and need to bypass this section)
Yes
No
Already vaccinated/already scheduled for vaccine appointment
N/A (please select only if you did not see a patient in clinic tonight and need to bypass this section)
Does the patient have reliable transportation to a vaccination site? Yes
No
Does the patient have either either: - A valid Florida ID card or a valid Florida driver's license? OR - Two forms of identification that prove their residency in Florida? Forms of identification accepted:
Category A: a deed, mortgage, monthly mortgage statement, mortgage payment booklet, OR residential rental or lease agreement Category B: a utility hookup or utility work order dated within 60 days before the date of vaccination Category C: a utility bill dated within two months of the date of vaccination Category D: mail from a financial institution, including checking, savings, or investment account statements, dated within two months of the date of vaccination Category E: mail from a federal, state, county, or municipal government agency, dated within two months of the date of vaccination Category F: if the person is a minor, proof of a Florida residential address for the individual's parent, stepparent, legal guardian, or other person with whom the seasonal resident resides in Florida, PLUS a written statement from the person with whom the seasonal resident resides stating that the seasonal resident does reside with him or her Yes
No
Yes
No
What is the patient's reason(s) for not getting the COVID-19 vaccine? (Check all that apply.)
If other, please explain:
Select to Enter Patient Information for Submission > * must provide value
Enter Patient Information
Enter Patient Information
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
Estimate Gestational Age based on:
LMP
EDD
First Date of Last Menstrual Period
Today M-D-Y
Estimated Delivery Date per LMP
View equation
Today M-D-Y
Estimated First Date of LMP per EDD
View equation
(hidden) GA at time of clinic visit in days
View equation
(hidden) GA today in days
View equation
(hidden) weeks without days for GA at time of clinic visit
View equation
(hidden) weeks without days for GA at time of clinic visit + w
(hidden) mod 7 calculation
View equation
(hidden) weeks without days for today's GA
View equation
(hidden) mod 7 calculation
View equation
View equation
View equation
GA at clinic (______ ) ______ W ______ D GA today ______ W ______ D
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.)
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
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
Spanish 7th Day: https://redcap.ctsi.ufl.edu/redcap/surveys/?s=AWRLDATDN9&nonproduction=overridestaffaccess&clinic_location=6&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.
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: ______ Prenatal: ______ 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.
If you ordered labs for your patient tonight, have you made sure to fill out their take-home lab form, ensure the information is correct, and given it to the patient?
YES - I have filled out the take-home lab form for the patient, ensured that their personal information is CORRECT (NAME & DATE OF BIRTH), and handed the form to the patient.
N/A - Patient did not have labs ordered at clinic today.
YES - I have filled out the take-home lab form for the patient, ensured that their personal information is CORRECT (NAME & DATE OF BIRTH), and handed the form to the patient.
N/A - Patient did not have labs ordered at clinic today.
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
Review Patient and Volunteer Information Patient: ______ was seen at ______ on ______ .
Research Study Selected: ______ Review Survey Submission Please confirm that all responses above are correct.
Once you confirm all information is correct the form will automatically ask you to submit.
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