• New Patient Form

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  • PAST MEDICAL HISTORY

  • Has any FAMILY MEMBER had any of the following problems (Please indicate relationship):

  • PATIENT INFORMATION

  • Please complete the following:

  • ALLERGIES

  • MEDICATIONS

  • SURGICAL HISTORY

  • HEALTH REVIEW

  • Please circle any symptoms you have had in the past 3 months:

  • The information provided here is true to the best of my knowledge. I authorize release of any previous medical records by fax, mail, or phone by either physician or hospital. Also, I hereby authorize the doctor or her assistants to initiate the diagnosis and treatment of my condition with x-ray, examination, or photographs of infections as necessary.

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  • I have personally reviewed the above information:

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  • Should be Empty: