Healthcare Reference Booth

HEALTHCARE REFERENCE BOOTH

This form documents the information you provide to staff at a healthcare reference booth for the purpose of receiving informational resources, referrals to health services, and follow-up contact if requested. Participation is voluntary. Information collected will be treated as confidential and used only for resource coordination, referral, and program evaluation unless otherwise authorized below or required by law. This booth does not provide emergency medical care or diagnoses.

PATIENT INFORMATION

Date of Birth:    Gender: Female Male Non-binary Prefer not to say

INSURANCE INFORMATION (IF APPLICABLE)

MEDICAL HISTORY & CURRENT NEEDS

Diabetes   Hypertension   Asthma/COPD   Heart disease   None listed

Primary Care Provider:    Phone:

Do you use tobacco products? Yes    Do you use alcohol? Yes    Are you pregnant or breastfeeding? Yes

SERVICES REQUESTED / INFORMATION NEEDED

Please indicate the types of information or services you would like from the booth (check all that apply):

Preventive screening information (blood pressure, cholesterol, cancer screening)
Immunizations / vaccine information
Chronic disease management resources
Mental health resources / counseling referrals
Substance use treatment resources
Dental care referrals
Health insurance / enrollment assistance
Social services (housing, food assistance)
Other (describe below)

COMMUNICATION & FOLLOW-UP CONSENT

I consent to receive follow-up contact and referral coordination from the program by the methods I select below. I understand messages may include appointment coordination, resource referrals, or screening reminders. I may revoke this consent at any time.

Contact by phone (voice call)   Contact by text message   Contact by email

AUTHORIZATION TO SHARE LIMITED INFORMATION

By signing below, I authorize staff at this booth to share limited information about my identified needs and relevant contact details with community health providers, clinics, or social service agencies for the purpose of making referrals and coordinating care. The information to be shared may include name, contact information, basic medical history relevant to the referral, and the services requested. This authorization does not permit release of complete medical records unless I sign a separate release.

I understand that information disclosed under this authorization may be re-disclosed by the receiving organization and may no longer be protected by federal privacy regulations. I also understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

Authorization expiration date (if none entered, authorization expires one year from signature):

PRIVACY & IMPORTANT NOTICES

Confidentiality: Information you provide will be kept confidential to the extent permitted by law. Staff may disclose information without your consent if required by law or to prevent imminent risk of serious harm to you or others, to report suspected child or elder abuse, or to comply with a court order or public health reporting requirements.

No Medical Treatment Provided: This booth provides information, screening, and referral services only. Staff are not diagnosing or treating medical conditions here. If you are experiencing a medical emergency, call emergency services or go to the nearest emergency facility.

Liability: The program and its staff will make reasonable efforts to provide accurate referrals and information but are not responsible for the actions, services, or quality of care provided by third-party agencies to which you are referred.

ACKNOWLEDGMENT & SIGNATURE

By signing below, I acknowledge that I have read and understand the information on this form, that I consent to receive information and referrals, and that I authorize sharing of limited information for referral coordination as described above. I understand I may revoke this authorization in writing.

Sign Now