EMS personnel may submit this form for patient follow-up requests. Your access to this information is contingent upon your involvement with the patient’s care. Follow-up information will only be provided to those directly involved with the patient’s care under compliance with state and federal rules and regulations.

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    MM slash DD slash YYYY
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  • Contact Information

  • MD, NP, PA, RN, EMT, EMT-P, etc.
  • MM slash DD slash YYYY

  • Patient Follow-Up

  • I was the (MD, Nurse, First Responder, EMT, RT, etc.)
  • This field is for validation purposes and should be left unchanged.