To: {#email#}
From: "Classic City Orthodontics" <system@classiccityorthodontics.com>
Subject: New Patient Referral 


{#date#}

Dear Classic City Orthodontics:

It is my pleasure to make the below patient referral:

{#introducing#}

{#introducing#}'s initial evaluation on {#initial_evaluation#} indicated {#comment#}

Needs X-ray: {#xray#}
Needs Panorex: {#panorex#}

-- 
Kind regards,

Dr. {#referring_doctor#}
{#email1#}
{#phone#}

----------------------------------------------------------------------

This form submitted on {#%DATE#} at {#%TIME#}
IP address is {#%REMOTE_ADDR#}

Powered By Ortho Infusion