Psychiatric Consultation, [select name="VisitType" value="Initial Visit|Follow-up Visit"]

CONSULT REQUEST INFO
Priority: [select name="urgency" value="Routine|ASAP|Discharge pending"]
Requesting provider:[text name="ReqProv" default=" "]
Details:[textarea name="ConsDet" default=""]
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IDENTIFYING INFORMATION
The patient is a [select name="Ethnicity" value="white|African-American|Hispanic|black|Asian||"] [select name="gender" value="male|female|**other"], age[text name="Age" default=" "] years, [select name="MarStatus" value="single|married|separated|widowed||in domestic partnership|"], [select name="Res" value="residing|homeless,||"] [select name="residence" value="home alone|home with family/caregiver|home with non-relatives|in assisted living facility|nursing home|group home|independent senior living setting|at homeless shelter||"] who was ******