T (503) 364-2181
F (503) 364-0364
www.childhoodhealth.com
THE FOLLOWING PATIENTS WERE REFERRED TO YOUR OFFICE AND WE HAVE NOT RECEIVED CHART NOTES FROM THEIR VISIT.
PLEASE RESPOND ON THIS FORM WITH THE STATUS OF THE REFERRAL.
IF THE PATIENT HAS BEEN SEEN, PLEASE FAX THE CHART NOTES TO 503.364.0364 ATTENTION MEDICAL RECORDS DEPARTMENT
Office:
Fax:
PATIENT NAME
DATE OF BIRTH
REFERRED ON
COMMENTS
THANK YOU - CHILDHOOD HEALTH REFERRAL DEPARTMENT
P 503.364.3170 F 503.587.0645
