Patient Follow Up Form

Please use the form below to request patient follow-up information. The following information is required in the message in order to process your request:

  • Name of Transporting Agency
  • Name of Treating EMS Provider
  • Receiving Facility (Good Samaritan or Lutheran)
  • Date of Transport
  • Approximate Time of Arrival at the Facility

DO NOT include any patient identifying information! Follow-up information will be sent to your agency's EMS leader for forwarding to the treating provider. Please allow 7-10 days to process your request.

Information will only be released to individuals with direct patient involvement and the agency's Quality Improvement representative.

Contact Information:
mm/dd/yyyy
hh:mm a.m./p.m.
Please do not include specific condition or disease information in the field below.

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