MyChart Login
Pay a Bill
Careers
Donate
Contact Us
Search
Find a Doctor
Services
Locations
Patients & Visitors
Resources
Research & Education
Get Care Now
Services
View all Services
Featured Services
Cancer & Blood Care
Heart & Vascular Care
Primary Care
Pediatrics
Women's Services
More Services
Behavioral Health & Psychiatry
Corporate Health
Emergency Care
Fitness & Health Pavilion
Imaging & Radiology
Laboratory Services
Neuroscience
Orthopedic & Sports Care
Pharmacy
Priority Care
Surgical Services
Patient Portal (MyChart®)
Patients & Visitors Overview
Care Everywhere Network
COVID-19 & Flu Information
Find a Baby Picture
Gift Shops
Volunteer
Patient Information
Medical Records
Patient Portal (MyChart®)
Pharmacy and Prescription Services
Patient Forms
Patient Privacy
Billing and Insurance
Pay My Bill
Financial Assistance
Pricing Estimates
Billing FAQs
Billing and Insurance Terms Glossary
Resources
Resources Overview
Blog
Health Library
Classes and Events
News
Community Education Classes
Research & Education
Research & Education Overview
Research
TriHealth Hatton Research Institute
Clinical Research
Clinical Trials
Academic Research
Research Process and Opportunities
Research Forms and Resources
Meet Our Research Team
Education
TriHealth Clinical Training and Testing Center
Continuing Medical Education
Graduate Medical Education
Residency Programs
Fellowship Programs
Medical Library for Physicians and Staff
Good Samaritan College of Nursing
Menu
Close
Search
Find a Doctor
Services
Locations
Patients & Visitors
Resources
Research & Education
MyChart Login
Pay a Bill
Careers
Donate
Contact Us
Services
Services
View all Services
Featured Services
Cancer & Blood Care
Heart & Vascular Care
Primary Care
Pediatrics
Women's Services
More Services
Behavioral Health & Psychiatry
Corporate Health
Emergency Care
Fitness & Health Pavilion
Imaging & Radiology
Laboratory Services
Neuroscience
Orthopedic & Sports Care
Pharmacy
Priority Care
Surgical Services
Patient Portal (MyChart®)
Patient Portal (MyChart®)
Patients & Visitors Overview
Care Everywhere Network
COVID-19 & Flu Information
Find a Baby Picture
Gift Shops
Volunteer
Patient Information
Medical Records
Patient Portal (MyChart®)
Pharmacy and Prescription Services
Patient Forms
Patient Privacy
Billing and Insurance
Pay My Bill
Financial Assistance
Pricing Estimates
Billing FAQs
Billing and Insurance Terms Glossary
Resources
Resources
Resources Overview
Blog
Health Library
Classes and Events
News
Community Education Classes
Research & Education
Research & Education
Research & Education Overview
Research
TriHealth Hatton Research Institute
Clinical Research
Clinical Trials
Academic Research
Research Process and Opportunities
Research Forms and Resources
Meet Our Research Team
Education
TriHealth Clinical Training and Testing Center
Continuing Medical Education
Graduate Medical Education
Residency Programs
Fellowship Programs
Medical Library for Physicians and Staff
Good Samaritan College of Nursing
Close
Search
Search
Common pages people are searching for:
Careers
MyChart Login
Contact Us
Pay a Bill
Donate
Home
/
Services
/
Emergency Care
/
EMS Patient Follow-Up Request
Emergency Care
EMS Patient Follow-Up Request
Emergency Care
Frequently Asked Questions
Rape Emergency Services (CARES)
EMS Clinical Rotation
TriHealth Emergency Journal
EMS Patient Follow-Up Request
Emergency Care Locations
Emergency Care
(513) 569-6111
Book an Appointment
Emergency Care Menu
Emergency Care
Frequently Asked Questions
Rape Emergency Services (CARES)
EMS Clinical Rotation
TriHealth Emergency Journal
EMS Patient Follow-Up Request
Emergency Care Locations
Call
Book an Appointment
Receiving Facility:
*
Bethesda North
Bethesda Arrow Springs
Bethesda Butler Hospital
Good Samaritan
McCullough-Hyde Memorial Hospital
Western Ridge
Date of Service:
*
Time of Arrival:
*
Patient Name:
*
Patient Age:
Sex:
Female
Male
Department Name:
*
Squad Member Name:
Contact Phone Number:
*
Additional Info or requests:
Submit