Last Updated: ________________
SCOPE should contact me by:
(Circle the best way to reach you)
My Contact Tree
•
Phone:
•
1. _________________
•
2. _________________
•
3. _________________
My child has a health issue I am concerned about.
•
I think this is an EMERGENCY.
CALL 911
Take SCOPE Toolkit with you to
Emergency Department
I think this is NOT an emergency.
It is an URGENT issue. I want to talk
with my primary care provider.
at ___________________
This is NOT urgent, but I would like to speak
to my SCOPE doctor within
Examples:
24 hours.
______________________
______________________
Examples:
After reaching the Emergency
Department, contact your SCOPE
doctor,
Dr. __________
E-mail: ___________________
I want to speak to another member
of my Care Team.
_______________________
_______________________
For ___________ issues,
contact _____________
at _________________
Contact your primary care provider
Contact your SCOPE doctor,
Dr. _____________
Dr. _____________
at __________________
at ____________________
For __________ issues,
If no answer in 24 hours, contact your
SCOPE mentor,
contact ____________
at _______________
Dr. _____________
at _______________________
For ___________ issues,
If no response from doctors above, contact
your SCOPE Directors,
Name: ___________________________
contact ____________
at _______________
at ______________________________
Patients: If there is a change in your care plan, please contact your SCOPE doctor.
SCOPE doctors: If using your cellphone, provide on outgoing message with instructions for emergencies.