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Available Forms

Alignment Care Center Appointment Request Alignment Referral Form Back Pain E-Visit Blood Pressure Log Blood Sugar Readings Cold/Sinus/Cough/Throat/Respitory Infaction E-Visit Conjunctivitis/Pink Eye E-Visit Depression Screening (PHQ9) Health Care Question Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam Prescription Refill Request Referral Question Specialist/Urgent Care or Hospital Visits Survey Triangle Medical Group Urinary Tract Infection E-Visit Yeast Infection E-Visit

Referral Question

Please complete this form for any questions or requests for referrals

Name *

Date of Birth *

Primary Insurance

Choose your medical practice

Request or Question

Preferred Method of Contact

Email

Work Phone

Home Phone

Cell Phone

Check all that apply

Preferred Contact Number or Email

* Required field