The ABC Health Connection, Inc.



	The ABC Health Connection Inc. 6800 West Loop South Suite 590, Bellaire, TX 77401 Telephone: 713.662.2869, Fax: 713.662.0555

	Client Referral Sheet

	Today's Date___________/________/___________

	Client Information:

	First Name: _______________________________		Last Name: _____________________________


	Birth date:____________/___________/________		Social Security Number:______-_____-________


	Address:____________________________________________________________________________ ____

	City______________________________, TX, Zip Code:____________

	Telephone numbers:

	Home (_________)_________________		Pager(_____)_____________________________

	Cell Phone (_____)_________________		or alternate (______)________________________

	Insurance Information:

	Name of your Health Insurance Provider:_________________________________________________________

	Policy number:________________________________________________

	Medicaid number:_____________________________________________

	CHIPS number_________________________________________

	Personal Information:

	When was your last regular period? _____/______/_____		How many days did it last?________________

	Are you experiencing any vaginal bleeding at this time? Yes/ No If yes, pleasedescribe: ______________________________________________________________________________

	Are you experiencing any pain? Yes/ No If yes, please describe:_______________________________________________________________________

	May we contact you by: Phone?______yes:______no:______ Mail?_______yes:________no:______

	FOR AGENCY USE ONLY. Thank you for your referral

	Name of your agency: ______________________________________________________________________

	Telephone number:__________________________		Name of a contact person: __________________________________

	The result of this client's pregnancy test is: POSITIVE_________________NEGATIVE_______________

	EDC/ Due date:________________________		Last Period:_________________________

	Name of examiner:______________________________ _		Date of the test:_______________________


	Reason for referral__________________________________________________________________________ _____________________________________________________________________________

	PLEASE PRINT AND FAX THE COMPLETED FORM TO : 713. 662.0555 OR CALL 713. 662.2869