Public Health Referral Form

Public Health Referral Form
1. Referring Organization/Provider Information
Select referral type
Organization/Provider Information
Organization/Provider Name
Organization/Provider Address
Phone Number
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Is this person aware you are making a referral?
Your relationship to this person:
2.a Patient Information
Full Name
Date of Birth

MonthDayYear
Patient birthdate
Is the patient considered a minor?
Gender

Other
Language preferred
Interpreter needed?
Address
Phone Number
Area code and phone numberFormat: (000) 000-0000.
How would you like to be reached?
Email
example@example.com
2b. If a minor, Parent/guardian contact information
Full Name
Date of Birth

MonthDayYear
Parent/guardian birthdate
Gender

Other
Language preferred
Interpreter needed?
Address
Best phone number to be reached
Area code and phone numberFormat: (000) 000-0000.
Email Address
example@example.com
How would you like to be reached?
Email
example@example.com
3. Referral Details
Reason for Referral: Check all that apply

Other (please specify)
Narrative: (please provide information on what you are requesting help with)

0/580
4. Clinical Information (if applicable)
Diagnosis Condition
Current Medications
Medical History
Allergies
Previous Referrals (if any)
If no previous Clinical Information, check here
5. Attachments
Please attach supporting documents here

pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, gif
Cancelof
If no attachments, check here
6. Electronic Consent

By checking the Consent box below, the organization, patient, or their legal guardian consents to the release of the above information for the purposes of receiving public health services from Blue Earth County Public Health.
Consent
Printed Name of Patient/Guardian
Date

MonthDayYear
Date of Consent
If you wish to receive an email confirmation of receipt of this form, please enter your email here:
example@example.com
Referrals will be processed upon receipt.

Questions?

Please call Blue Earth County Public Health intake line at 507-304-4117 regarding questions if needed.
Should be Empty: