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REFERRAL Dr. Shawn Jordan
Dr. Cynthia Czaperacker
Dr. Anthony DomenicoPatient Name: ___ Referred Date: ___
Tooth Number(s): ___
Condition/Notes:___125 Grand Island Blvd
Lawanda, NY 14150
(See reverse
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How to fill out re ferr al
01
Obtain the necessary referral form from your healthcare provider
02
Fill out your personal information such as name, date of birth, and contact information
03
Provide details about the reason for the referral and the specialist or service you are being referred to
04
Double check all information for accuracy and completeness before submitting the referral
Who needs re ferr al?
01
Individuals who require specialized medical care beyond the scope of their primary care physician
02
Patients who need to see a specialist or receive a specific medical service
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What is re ferr al?
Referral is the act of sending someone to another person or resource for help or information.
Who is required to file re ferr al?
Certain individuals or organizations may be required to file a referral based on specific circumstances or regulations.
How to fill out re ferr al?
Referral forms typically require information about the person making the referral, the person receiving the referral, and the reason for the referral.
What is the purpose of re ferr al?
The purpose of a referral is to connect someone in need with the appropriate assistance or services.
What information must be reported on re ferr al?
Information such as the names of the individuals involved, the reason for the referral, and any relevant background information may need to be reported on a referral form.
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