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Incident

LL Medical Intake Generator

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Please fill out the form below and then click submit. You will be directed to a confirmation page with a number to be added to the PCR. Do not provide any HIPAA protected info on this form.

Intake Info

Date/Time of Intake (NOTE: Be sure to include time)^*

Medical Location^*

Patient Chief Complaint^*

Brief Summary - NO HIPAA PROTECTED INFO!^*

Select Event Day (TODAY'S EVENT)^*

Please attach this confirmation number to the patient's PCR. Your Incident ID is #

DO NOT INCLUDE ANY HIPAA PROTECTED INFORMATION ON THIS FORM

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