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.
Please list all prescription and non-prescription medications, vitamins, home remedies, birth control, herbs etc.
List all reactions to medicines, foods, and other agents.
PERSONAL MEDICAL HISTORY
HOSPITALIZATONS: Please list all prior hospitalizations and dates
Who lives at home with the patient?
Please indicate with a check (√) any current problems your child has on the list below.
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