Community Paramedic Program Patient Referral

The Community Paramedic Program provides home visits and general wellness assessments to residents in the Township of Wainfleet.

A referral can be made by the resident themselves, their health care professional, a family member, another caregiver agency, or even a neighbour.

After the referral form is received, the individual will be contacted by the community paramedic or a registered nurse working within the Niagara Ambulance Communications Centre.

Patient Referral Form

* = Required

Patient Information

Date of Birth

Family Physician Information

* Preferred Contact

Referring Physician Information

Preferred Contact

Referral Information

Patient Consent   

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