Referring Provider
For Fax, Merced
(209) 349-8518
, Fresno
(559) 369-4418
Referral-Reason
Submitted-On
Select Office
Fresno
Merced
Telemedicine
Allergies
Allergic Rhintis
Asthma
Atopic Dermatitis
Hives/Urticaria
Sinusitis
Drug Allergy
Food Allergy
Chronic Cough
Bee/Stinging Insect Allergy
Nasal Polyps
Vaccine Allergy
Immunodeficiency
Metal/Prosthesis Allergy
Contact Dermatitis
Anesthesia Allergy
Patient-Information:
Date of Birth:
Male
Female
Referring Physician
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