Charm City Clinic Client Referral
Please enter relevant information in the below box. All responses are confidential and stored in a HIPAA compliant manner. If you would like to fill out a paper form instead, please see: https://drive.google.com/file/d/0B_ogsNCFaq2_NEFOZENfbnptdTQ/view?usp=sharing

Our walk in hours are Tuesdays from 6 - 9 PM and Saturdays from 12-5 PM.

If you have any questions, please email our program manager, Tulha Siddiqi at tsiddiqi@charmcityclinic.org.

Client Name
Your answer
Client Phone Number
Your answer
Referring Organization
Your answer
Organization Point of Contact Name
Your answer
Point of Contact Phone Number
Your answer
Point of Contact Email
Your answer
Reason For Referral
(insurance/unpaid medical bills/MCO change/etc.)
Your answer
What day/time did you ask this client to come to the clinic?
Our walk in hours are Tuesdays from 6 to 9 PM and Saturdays from 12 - 5 PM
Your answer
If client consents, I would like updates on how this client's visit went.
Submit
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