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[text memo="name" memo_color="blue" memo_size="small" size="15"],

We've received your message. we'd be happy to help you with that issue.
In order to help you, we need to know the following:

[checkbox memo="referral" memo_color="blue" memo_size="small" name="smsreferral" value="For each requested referral, please provide:"][conditional field="smsreferral" condition="(smsreferral).is('For each requested referral, please provide:')"]
-What condition or diagnosis?
-What specialty?
-Have you previously been seen by this specialty?
-If so, how long ago?
-If so, are you desiring to still be seen by the same specialist?
-If you still want to be seen by the same specialist, please provide:
-Name of specialist
-Name of office/business
-Address of office
-FAX and Office phone number of office

[/conditional][checkbox memo="med refill" memo_color="blue" memo_size="small" name="smsmeds" value="For each requested medication, please provide:"][conditional field="smsmeds" condition="(smsmeds).is('For each requested medication, please provide:')"]
-What condition or diagnosis is it for?
-Exact name and strength of medication? (for example, claritin 10mg or hydrocortisone cream 1%)
-How often and how much do you use? (for example, 1 tablet twice a day or applied to affected skin three times a day)
-Do you take/use this regularly or occasionally/as-needed?
-Is this medication working well for the benefit you or your doctor intended?
-What side effects of this medication are you experiencing?

[/conditional][checkbox memo="test request" memo_color="blue" memo_size="small" name="smstestrequest" value="For each requested test, please provide:"][conditional field="smstestrequest" condition="(smstestrequest).is('For each requested test, please provide:')"]
-What condition or diagnosis is this test for?
-What is the specific reason you are requesting this test?
-When were you last evaluated by a doctor for this condition?

[/conditional][checkbox memo="test result" memo_color="blue" memo_size="small" name="smstestresult" value="For each test for which you are wanting results, please provide:"][conditional field="smstestresult" condition="(smstestresult).is('For each test for which you are wanting results, please provide:')"]
-What test was done?
-How long ago was the test performed?
-Why was the test ordered?
-What specialty and name of doctor that ordered test?
-What is your biggest concern or worry regarding the results of this test?

[/conditional]
name,

We've received your message. we'd be happy to help you with that issue.
In order to help you, we need to know the following:

referral med refill test request test result

Result - Copy and paste this output:

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