Calvert County Health Department Referral Form
Please complete this form for your patients who would benefit from one or more of our services.  No medical referral required.  
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Name of patient and their DOB *
Date of referral *
MM
/
DD
/
YYYY
Patient phone number and email *
What is the preferred option for outreach from the CCHD?
Clear selection
Referring provider name *
The patient verbally consents to the following: "I agree to share the health information listed on this form with the Calvert County Health Department for follow up". *
Required
Which program are you referring your patient to? *
Is a Spanish Interpreter needed for your referral?
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For diabetics, please enter most recent A1c and date of test.
For pre-diabetics, please enter most recent A1c and date of test.  
For smokers, please clarify what type of product to which the patient is addicted.
Clear selection
Submit
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