Calvert County Health Department PROVIDER 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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Email *
Name of patient and their DOB *
Date of referral *
Patient phone number and email *
What is the patient's preferred options for outreach from the CCHD?
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". *
Which program are you referring your patient to? *
Is a Spanish Interpreter needed for your referral?
Clear selection
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
For those with hypertension, please enter most recent BP measurement and date of check.
If referring to Highway to Health, please list area(s) of need.
Is this an internal CCHD referral?
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A copy of your responses will be emailed to the address you provided.
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