Tuberculosis Program Patient Referral

Tuberculosis Program Patient Referral
Reason for Referral (check all that apply)
Links:

Signs and Symptoms of Tuberculosis

Tuberculosis Risk Factors

Referring Hospital, Clinic or Healthcare Provider Information
Name

First NameLast Name
Credentials
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
FaxNumber
Please enter a valid phone number.Format: (000) 000-0000.
Is there someone else that will be a contact for additional information:
Contact Name

First NameLast Name
Contact credentials
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Please mark and upload any of the following with your referral:
Please upload any documents pertaining to TB test, X-rays, Clinical notes, or Lab results.

Cancelof
Contact the Larimer County Department of Health and Environment (LCDHE) TB Program with any questions:

Email: TBprogram@larimer.org
Phone: 970-498-6789
Fax: 970-498-6772
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