Patient Information Form

West Hartford Podiatry

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EMERGENCY CONTACT

I certify that the information given above is true and correct. I understand that it is my responsibility to notify West Hartford Podiatry Associates of any changes to the above information. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

HISTORY & MEDICAL INFORMATION

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10. Surgical History:

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