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.
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