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Sterling Family Medicine Referral Form

Thank you for your interest. Kindly fill out the form below to the best of your ability. We will contact you within 24 hours or next business day. If this is a medical or psychiatric emergency, please call 911.

    1) Patient Name

    2) Date Of Birth

    3) Phone Number

    4) Email

    5) Reason for referral:

    6) Please explain the reason for your referral:

    7) Please give an alternate person to contact if patient cannot be reached or speak for themselves

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