Patient Referral

Patient First Name

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Patient Last Name

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Date of Birth

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Patient Email

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Patient Phone Number

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Referring Provider’s name

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Provider’s Phone Number

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Provider’s Email

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Additional Comments

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Please check to confirm this patient has been diagnosed with Type 2 Diabetes AND has an A1c over 8 OR is using insulin. We only serve patients with Type 2 Diabetes with A1cs over 8 or using insulin.

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