{header1} {label_subhead_clinic}
{label_clinic_id} {fac_facility_npi}
{label_clinic_id} {ref_pid}
{label_control_no} {ref_id}
{label_date} {ref_refer_date} 
{label_name}   {pt_title} {pt_fname} {pt_mname} {pt_lname}    {label_age}   {pt_age}    {label_gender}   {pt_sex} 
{label_address}   {pt_street}, {pt_city} {pt_state}    {label_postal}   {pt_postal_code}    {label_phone}   {pt_phone_home} 
{label_ref_reason}   {ref_body} 
{label_diagnosis}   {ref_refer_diag} 
{label_ref_class}   {ref_refer_risk_level} 
{label_dr_name_sig}   {ref_refer_from} 
{label_refer_to}   {ref_refer_to} / {to_organization} 

{header1} {label_subhead_patient}
{label_clinic_id} {fac_facility_npi}
{label_clinic_id} {ref_pid}
{label_control_no} {ref_id}
{label_date} {ref_refer_date} 
{label_name}   {pt_title} {pt_fname} {pt_mname} {pt_lname}    Age   {pt_age}    {label_gender}   {pt_sex} 
{label_clinic}   {to_organization} 
{label_address}   {to_street}, {to_city} {to_state}    {label_postal}   {to_zip}    {label_phone}   {to_phone} 
{label_ref_reason}   {ref_body} 

 
{label_history_summary}:
{label_bp}   {v_bps}/{v_bpd}    {label_ht}   {v_height}    {label_wt}   {v_weight} 

{label_ref_name_sig}   {ref_refer_from} 
{label_special_name_sig}   {ref_refer_to} 


{header2} {label_subhead_referred}
{label_clinic_id} {fac_facility_npi}
{label_clinic_id} {ref_pid}
{label_control_no} {ref_id}
{label_date} {ref_reply_date} 
{label_name}   {pt_title} {pt_fname} {pt_mname} {pt_lname}    {label_age}   {pt_age}    {label_gender}   {pt_sex} 
{label_clinic}   {to_organization} 
{label_diagnosis}   {ref_reply_init_diag} 
{label_findings}   {ref_reply_findings} 
{label_final_diagnosis}   {ref_reply_final_diag} 
{label_services_provided}   {ref_reply_services} 
{label_recommendations}   {ref_reply_recommend} 
{label_scripts_and_referrals}   {ref_reply_rx_refer} 
{label_special_name_sig}   {ref_refer_to}