San José Clinic Monthly Reporting Form

Monthly Reporting Form

The information submitted in this form will be transmitted to the administration of the SBFDC. This information is reviewed and later aggregated to the information previously provided by the San José Clinic staff, compiled with the the information provided by the other collaborating partners from the SBFDC and later presented to the Board of Directors. The information is needed by the Monday before the first Thursday of the month.

If the reporting needs for the San José Clinic staff change, or if you have any questions about the information please contact us @ 713-996-8781 or via e-mail.

First Name *	Last Name *
e-mail *	Phone *
Agency	Month reporting for

* These are required fields.

Gynecology Patient Visits
		Total Gynecology Visits

Pediatric Patient Visits
		Total Medical Visits

Dental Patient Visits
		Total Dental Visits

Eligibility Visits
		Total Eligibility Visits

Starting in 2004 we are tracking how clients are referred from one provider to another when appropriate. In order to have a better understanding of this dynamic please complete the following information.

From collaborating partners from SBFDC

Received client referrals from

From External Sources

Received referrals from

Referrals made to collaborating partners from SBFDC

Made client referrals to

Referrals made to external sources

Made referrals to

Did San José Clinic have any Special Events? Yes No

Comments:

Thank you for your time and information.