{header1} {label_subhead_clinic}

{label_client_id} {pt_pubpid}  {label_date} {ref_refer_date}

 
{label_history_summary}:

{label_bp}

{v_bps}/{v_bpd}

{label_ht}

{v_height}

{label_wt}

{v_weight}

{label_name}

{pt_title} {pt_fname} {pt_mname} {pt_lname}

{label_age}

{pt_age}

{label_gender}

{pt_sex}

{label_ins_name}

{insurance_provider_name}

{label_ins_plan_name}

{insurance_plan_name}

{label_ins_policy}

{insurance_policy_number}

{label_ins_group}

{insurance_group_number}

{label_ins_date}

{insurance_date}

{label_address}

{pt_street}, {pt_city} {pt_state}

{label_postal}

{pt_postal_code}

{label_phone}

{pt_phone_home}

{label_ref_reason}

{ref_body}

{label_diagnosis}

{ref_refer_diag}

{label_ref_class}

{ref_refer_risk_level}

{label_dr_name_sig}

{ref_refer_from}

{label_refer_to}

{ref_refer_to} / {to_organization}

---

{header1} {label_subhead_patient}

{label_client_id} {pt_pubpid}  {label_date} {ref_refer_date}

{label_name}

{pt_title} {pt_fname} {pt_mname} {pt_lname}

Age

{pt_age}

{label_gender}

{pt_sex}

{label_ins_name}

{insurance_provider_name}

{label_ins_plan_name}

{insurance_plan_name}

{label_ins_policy}

{insurance_policy_number}

{label_ins_group}

{insurance_group_number}

{label_ins_date}

{insurance_date}

{label_clinic}

{to_organization}

{label_address}

{to_street}, {to_city} {to_state}

{label_postal}

{to_zip}

{label_phone}

{to_phone}

{label_ref_reason}

{ref_body}

 
{label_history_summary}:

{label_bp}

{v_bps}/{v_bpd}

{label_ht}

{v_height}

{label_wt}

{v_weight}

{label_ref_name_sig}

{ref_refer_from}

{label_special_name_sig}

{ref_refer_to}

{header2} {label_subhead_referred}

{label_client_id} {pt_pubpid}  {label_date} {ref_reply_date}

{label_name}

{pt_title} {pt_fname} {pt_mname} {pt_lname}

{label_age}

{pt_age}

{label_gender}

{pt_sex}

{label_ins_name}

{insurance_provider_name}

{label_ins_plan_name}

{insurance_plan_name}

{label_ins_policy}

{insurance_policy_number}

{label_ins_group}

{insurance_group_number}

{label_ins_date}

{insurance_date}

{label_clinic}

{to_organization}

{label_diagnosis}

{ref_reply_init_diag}

{label_findings}

{ref_reply_findings}

{label_final_diagnosis}

{ref_reply_final_diag}

{label_services_provided}

{ref_reply_services}

{label_recommendations}

{ref_reply_recommend}

{label_scripts_and_referrals}

{ref_reply_rx_refer}

{label_special_name_sig}

{ref_refer_to}