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Desoto County Health Department Dental Clinic Triage Form INFORMATION YES ARE YOU A NEW PATIENT Last name NO First Middle Street address P. O. box Home Phone Number State City Emergency Contact Not Living With You Name Birthdate Social Security Number ZIP Code Phone Address OTHER INFORMATION STATUS Single Married INSURANCE INFORMATION Separated NONE Divorced GROUP Widowed ID HOUSEHOLD STATUS/EMPLOYMENT INFORMATION Name of Employer OTHER INCOME Child Support Retirement SSI AFDC/Food Stamps VA Benefits Unemployment Benefits Worker s Compensation Contributions from friends/relatives Student Loans None REASON FOR VISIT PLEASE LIST YOUR PRESENT HEALTH CONCERNS PROBLEMS OR SYMPTOMS AUTHORIZATION FOR TREATMENT I HEREBY CERTIFY THAT ALL INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE* I HEREBY APPLY FOR AND GRANT PERMISSION TO RECEIVE ALL NECESSARY MEDICAL TREATMENT AVAILABLE THROUGH THE DESOTO COUNTY HEALTH DEPARTMENT FOR MYSELF AND/OR MY FAMILY. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE ....

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The injured people are placed in four urgent (red), emergency (yellow), delayed (green) and non-salvageable (black) classes.

The triage scale consists of 3 levels: category 1 (immediate), category 2 (urgent), and category 3 (non-urgent).

If the patient requires two or more hospital resources, the patient is triaged as a level 3. If the patient needs one hospital resource, the patient would be labeled a 4. If the patient does not need any hospital resources, the patient would be labeled a 5.

Triage is utilized in the healthcare community to categorize patients based on the severity of their injuries and, by extension, the order in which multiple patients require care and monitoring. The history of the emergency triage originated in the military for field doctors.

Triage categories Immediate category. These casualties require immediate life-saving treatment. Urgent category. These casualties require significant intervention as soon as possible. Delayed category. These patients will require medical intervention, but not with any urgency. Expectant category.

The triage categories used in both systems are: Red (immediate evaluation by physician), Orange (emergent, evaluation within 15 min), Yellow (potentially unstable, evaluation within 60 min), Green (non-urgent, re-evaluation every 180 min), and Blue (minor injuries or complaints, re-evaluation every 240 min).

Level 1 (resuscitation) requires immediate, life-saving intervention. Level 1 includes patients with cardiopulmonary arrest, major trauma, severe respiratory distress, and seizures. Level 2 (emergent) requires an immediate nursing assessment and rapid treatment.

To ensure that patients with more serious conditions are ed higher priority in medical treatment, HA adopts a triage system which classifies patients attending the A&E Departments into five categories ing to their clinical conditions: critical, emergency, urgent, semi-urgent or non-urgent.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232