Your form "Client Referrals " has received the following response:
1/15/2019 14:53
Completion time: 8 min.

Client Name and Address
Linda Armstrong
 806-773-3039
Client Email

5526 E COUNTY RD 6560
Lubbock
TX
Client Postal Code
79403
County
Lubbock

Additional Client Information
Client's Age at Referral: 70
DOB: 6/9/1948
Client's Gender: Female
Client's Ethnicity: Caucasian
Is this a hospice patient? No
Is this a dialysis patient? Yes
Is this a handicapped person living alone? Yes
Did this person serve in the military? No

Client Financial Information
Is there a financial need, based on your agency's guidelines? Yes
Does the Client Own or Rent their home? Own

Caretaker/Other Contact Information
Caretaker /Other Contact  Name

Caretaker/Other Contact Phone

Ramp Information
Where is the ramp needed? Ramp is needed in front of the house.
Description of obstacles(s): Pt uses a walker and is difficult to maneuver her walker down 2 steps.
Details of mobility
Pt uses a walker. Prognosis is not expected to change. The Pt will continue to need to use a walker

Is there an existing dangerous ramp at the client's home? No

Referring Social Worker Information
Referring Social Worker Full Name: Shay Carranza
Name of Referring Agency: Heart of Lubbock Dialysis
Referring Social Worker's Phone: 806-744-1252
Referring Social Worker's Email: danica.carranza@fmc-na.com