Referral form for Dr. Angela Cortal

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Please submit as much or as little information as you would like for your referral below:

Your name: *

Clinic name:
*

What are you referring for? (my office will follow up to obtain medical records, this is just a general sense of what you are looking for with the referral)
*

I will personally respond to your inquiry within 1-3 business days. How would you like the response?
*

Phone call

Text

Fax

Contact info (phone #, email, or fax # as indicated above):
*

Are there additional records you would like us to obtain from any other facility (such as lab or imaging reports)? If so, please indicate the facility and records type below:

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This form was created inside of Angela Cortal.