Appointment Intake Questionnaire Screening Form

Orchard Medical Center, S.C. (OMC)

Please correct the errors described below.

PATIENT INFORMATION & APPOINTMENT REQUEST

CURRENT MEDICATIONS

List ANY Prescribed Medications You Are Taking Including Strength and Duration

LIST ANY RECENT VISIT TO HOSPITAL, ER, ACUTE CARE CENTER, TAKE CARE CLINIC, WALK-IN CLINIC

Currently Under the Care of:

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