If Yes, Please give the benefits card to the patient service representative when you check-in
Please write in an answer or circle yes or no to all the questions below.
Have you been previously diagnosed with any of the following? (Check all that apply or None )
If YES, please list the person's name and contact number below.
(Check all that apply or check none.)
List all medications you are currently taking. Include prescriptions over the counter medications, vitamins, and herbals. Use additional paper if needed. Please notify our office if you decline to have your medication list imported from participating pharmacies.
PLEASE GIVE YOUR PHARMACY INSURANCE CARD TO THE FRONT OFFICE AT CHECK IN TO HELP FACILITATE YOUR MEDICATIONS ARE AUTHORIZED PROPERLY.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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