Referral Response Form

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Variety Care Referral Follow Up

At your last visit we referred you for specialty care. We want to make sure the appointment was made. Please be aware we can only assist with updates on this current referral, if you have any other questions or requests please call our office at 405-632-6688.
Name of Patient *

First Name Last Name
What is the patient's date of birth? *

Month Day Year
Date
Who is your Variety Care provider? *
Which specialty referral are you responding to? *
Was the appointment with a specialist made? *

Yes No I need assistance
What date is/was the appointment with the specialist?

Month Day Year
Date
No, appointment was not made:

I have their number and I will call I need to cancel my referral
What type of assistance do you need?
Should be Empty:

Variety Care Referral Follow Up