Calontir Chirurgeons' Patient Encounter Form

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Calontir Chirurgeons’
Patient Encounter Form
(Long Form)
Patient Information:
Person’s SCA Name:
______________________________________________________________________
Person’s Modern Name:
First: __________________
MI:
_____
Last:
_____________________
Date of Birth: ____ / ____ / ______
Age: ___
Is this person a Minor? Yes / No
Address
Street
______________________________________________________________________
City
_______________________________________
State
_____
Zip Code
_____
Telephone
Home: ____ - ____ - ______
Cell:
____ - ____ - ______
Emergency Contact Information:
Modern Name: ________________________ Telephone: Home: ____ - ____ - ______ Cell: ____ - ____ - ______
Minor Permission to Treat:
I (name -- please print): _________________________________ give the Chirurgeon(s) permission to administer
First Aid to my daughter / son (name -- please print):
________________________________________________
Signed:
_______________________________
Date: ____ / ____ / _______
Relationship to Minor: Parent / Guardian
Incident Information
Location of Incident: ________________________________________________________________________
Date: ____ / ____ / ______
Time notified ____ : ____ am/pm
Time at Patient ____ : ____ am/pm
Time Released ____ : ____ am/pm
Released to: _______________________________________________
Was EMS Called: Yes / No Time EMS Called ____ : ____ am/pm Time EMS Arrived ____ : ____ am/pm
Time Transferred ____ : ____ am/pm
Transferred to ___________________________________________
Time Transported ____ : ____ am/pm
Transported to ____________________by_____________________

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