Medical History

Please correct the errors described below.

1. Do you have or have you had any of the following conditions?

2. List any past illness or surgery for which you were hospitalized.

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3. List and describe any allergies to medications and other substances.

4. List any current medications (include prescription and non-prescription drugs)

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Central Connecticut Foot Care Center, LLC Disclosure Agreement

Example: self, father, mother, legal guardian, other (specify)

If yes, please provide us with names and phone numbers below:

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May we leave personal medical information on your:

My signature below indicates I have received and/or reviewed a copy of the Privacy Practice Policy of this office and have agreed to the release of my health information as indicated above.

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.

Your information will be encrypted.