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September 9, 2010 Charles M. Clark, M.D. 1750 N Medical Way Mesa, AZ 85210
Dear Charles M. Clark, M.D., We have referred the following patient to your office for consultation and treatment. |
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Patient Name Address
Home Phone Work Phone Gender Date of Birth Social Security Number Employer
Primary Insurance Secondary Insurance Last Visit Date |
Patricia Abbott 608 S 500 W Murray, UT 84123 375-1586
Female 09/30/1963 778-56-1123 J.C. Penneys 300 University Mall Orem, UT 84057 224-1311 Connecticut General Metlife 08/10/2010 |
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Please refer to the enclosed patient records and contact my office if you have any questions. Also, please keep us informed of any treatment you render or conditions you find that will assist us in our efforts to maintain good dental health for our patient. It's always a pleasure working with you! Sincerest regards,
Dennis D. Smith, D.D.S. |
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