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Referral Form
This referral form is used strictly for health purposes only. TriCounty Health Department is a HIPAA compliant agency and all healthcare information will be protected. You may also refer patients by contacting TriCounty Health Department directly.
Email address *
I acknowledge that I have given my provider permission to share some health information with TriCounty Health Department. This may include lab work, contact information, etc.
What program are you being referred for?
What is your preferred method of contact?
Please provide your contact information
Your answer
What is the best time of day to contact you?
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