Download the file by hitting the button to the left It is 2 pages a blank sample and a completed sample.
It is a pdf format which you should still be able to use and fill in. I could not improt the MS Word document into my website manager.
If it does not work then just recreate in WORD or send me an email with your clinic info and I can make one for you.
Make sure you send your logo too if you need me to create one for you.