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2502 E. Oakland Park, Fort Lauderdale

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Patient History Form

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  • Patient History Form

  • Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
  • Please help us take better care of your overall health by completing the following form

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide your email address.
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0000 to 9999.
  • PLEASE CHECK ALL THAT APPLY

  • MEDICAL HISTORY

  • REVIEW OF SYSTEMS

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Patient History Form | Patient Information Form

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