Fax Copy of PPCR to PEMS at (804) 693-6277

Date:              Time:      PPCR # (Fax Copy to PEMS)

EMS Agency:

Technician(s):               

Receiving Facility:         

Receiving Physician:

Submitted by (Please include an e-mail address): 

Reason for Review (check appropriate boxes):

Unable to establish contact with Medical Control:
        Physician /Not Available         Communications Failure

Medical Control treatment needed but not performed:
     Life-threatening situation             Non-life-threatening situation

Medical Control treatment initiated without physician order:
        Life-threatening situation             Non-life-threatening situation

Regarding treatment orders from on-line Medical Control physician

Regarding EMS patient treatment or actions