RT3 Physicians Order Form

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RT3 Physicians Order Form

This is a sample COVID Rural Testing & Tracing Toolkit (RT3) Physician Order Form. Make a copy of this form and then alter that one as you see fit.

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* Indicates required question

Patient Name *

Your answer

Patient Birthdate *

MM

/

DD

/

YYYY

Patient Phone Number

Your answer

Patient Email *

Your answer

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