ADVOCACY PARTNERS Service Commitment Support Dreams Doctor Visit Report Person Served Date Doctor

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ADVOCACY PARTNERS Service Commitment Support Dreams Doctor Visit Report Person Served Date Doctor Powered By Docstoc
					                           ADVOCACY PARTNERS
                  Service. . .Commitment, Support, Dreams
                               Doctor Visit Report

Person Served: ________________________________________Date: ______________

Doctor: __________________________________________Specialty: ______________

Address: ________________________________________________________________

City, State and Zip: _______________________________________________________

Telephone Number: _______________________________________________________

Reason for Visit: _________________________________________________________

Diagnosis/Treatment: ______________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Please list changes or current prescriptions below:
Medication            Dose                 Route           Frequency         Purpose




Doctor’s, PA’s or Specialist’s Signature:
_______________________________________

(Please attach all relevant clinic notes, referral forms, Rx forms, and lab reports prior to
submission to AP)




Advocacy Partners Doctor Visit Report revised 01/05 (AO)