UMMC Sickle Cell Follow-Up Contact Form

Patient Type

Patient Full Name

Phone

Date of Birth

Month

Day

Year

This helps physicians identify the correct patient quickly.

Parent/Guardian Full Name

Parent/Guardian Phone Number

Parent/Guardian Email

Briefly describe urgency (Do not include detailed medical records or sensitive personal health information)

Primary Sickle Cell Physician Name

I authorize the Mississippi Sickle Cell Foundation to share the information provided in this form with my (or my child’s) primary sickle cell physician and/or the appropriate UMMC sickle cell team for follow-up coordination.

I understand this form is NOT for medical emergencies. If experiencing a life-threatening emergency, I will call 911 or go to the nearest emergency room.

UMMC Triage Line: 601-815-0000

Leave a message for medication refills, appointments, or transfusions.

This prevents the Foundation from becoming the primary intake system.