You may either type in the fields and print or print a blank copy to complete manually.

If there are multiple patients to refer, you have the option of clearing just the patient data so another patient’s info can be entered without having to retype the referring provider’s info.

Please Note:
If you print the completed form but the data in the fields isn’t visible…

• click the Print button at the bottom of the form

• in the Print dialog box, click Advanced (usually beside the printer select dropdown menu)

• click Print as Image