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  • After Hour Pediatrics Urgent Care Clinic

    PATIENT HISTORY
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  • FAMILY HISTORY

  • OTHER CONCERNS / ROS

  • CONSENT / FOLLOW UP INFORMATION

  • For follow-up,such as lab results,X-ray reports,or billing matters,I prefer AHP to notify me by phone or email at:


    If AHP cannot reach me by phone, I authorize AHP to leave a detailed message about the care of the patient.
    I certify that the above information is true and I consent to any medical or surgical treatment rendered to the patient under the general or special instructions of the physician.
    I understand I may review in detail AHP's Privacy Practices. I am aware of my right to request special privacy considerations.

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  • Birth History: Wgt. Problems .

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