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Site-Logo   Emergency Department Call-In

Patient Last Name Patient First Name Age
Person Calling In   Gender
Patient's usual Provider    
Clinical Summary
(Please include: Brief 1-2 paragraph history, Consultant preferences, Admission preferences)
Admission Service Service  
After evaluation, contact Via Number/Address

Information entered about patients ALREADY registered in the Emergency Department
may be missed, and a direct phone call should be placed to 617-313-1615

This is a transfer between Emergency Departments.

Note: Transfers between departments must be accepted by the Attending Physician at the receiving Emergency Department.

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