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
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: 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
Spanish
Other
English
Spanish
Other
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?
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
Spanish
Other
English
Spanish
Other
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?
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?
Yes
No
The option "
¿Tiene usted los síntomas de abajo?
* must provide value
The option "
¿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:
Si han pasado 10 días (o mas), síntomas están mejorándose y no hay fiebre:
Si han pasado 10 días (o mas), desde la fecha de su prueba, no tiene síntomas y no hay fiebre:
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.]
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.
¿Padece usted de otras condiciones o enfermedades?
Yes
No
¿Cuales?
¿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.
* must provide value
Confirm
Cancel
Please confirm that the patient is being referred to medical monitoring.
* 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:
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 * 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.
Yes // Sí
No // No
If EAC were to start offering prenatal care, would you be interested in obtaining your care
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:
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 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
Does the patient have a diagnosis of asthma? Yes
No
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?
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
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
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.
Who to Refer: Services offered: Benefits to Patients Clinic Location and Times: 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.
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.
Other Local Dental Resources
WeCare Dental Resources No WeCare forms are required and the eligibility criteria is not as strict as other WeCare referrals. Reason for dental referral?
What is the patient's dental pain level?
Thank you! We have all the information we need for a dental referral and our dental team will follow up with the patient.
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:
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 M-F 0700-1700 with questions
Clinic Location and Times:
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?
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
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.
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:
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.
Equal Access Clinic Gynecology Night
Who to Refer:
Services offered:
Clinic Location and Times:
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.
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.
General Services
Hormone Therapy
General Services
Hormone Therapy
Hormone Therapy
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?
Reason for Nephrology Referral?
Uncontrolled Hypertension
Uncontrolled Diabetes
History of/Concern for Chronic Kidney Disease
Electrolyte Abnormalities
Other
Uncontrolled Hypertension
Uncontrolled Diabetes
History of/Concern for Chronic Kidney Disease
Electrolyte Abnormalities
Other
Please specify why you're referring this patient to Nephrology Night
Thank you for your referral to Nephrology Night!
Confirm Referral
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: If a patient answers "Yes" to 2 or more of the above questions, they would benefit from occupational therapy services.
Services offered:
Follow this link for referral submission (opens in a new window)! (HIDDEN) Patient Reminder
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 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 Location and Times:
When: Last Tuesday of each month, patients to arrive at 5:00 PM, patients are seen starting at 5:30 PMWhere: 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?
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 costswww.alachuacounty.us Gainesville Community Ministry Vision Clinicwww.betterday.org Helping Hands Clinic First United Methodist Church-Provides referrals for eye exams and eyeglasses for the homeless.www.hhcg.org Officer Override
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.
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: Services offered: Clinic Location and Times: 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. Referral Form (required if paper copy not submitter via referrals officer):
PT Referral form (updated)
Patient Reminder Contact Patient
Cancel
NEW - EACN Psychiatry
We are able to diagnose and treat: - 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***
Other Community Resources:
Referral Information Please include: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: Services offered: Clinic Locations: Which location would the patient like to attend?
Please briefly describe the patient's need for referral.
* must provide value
Please briefly describe "Other" indication;
* 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 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: Services offered: Clinic Location and Times: What type of imaging would you like to order?
Screening imaging (mammogram) = ______
Please indicate urgency of referral:
Routine
Urgent
Please indicate the service requested:
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:
Important Information for your Patient's Prep 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. Referrals can ONLY be placed through the clinic navigator. DO NOT contact MOC directly about your patient.
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
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