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Intake for First Telemedicine Visit
Full Name
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Address
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Apartment #
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State
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Zip Code
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Home Phone
Cell Phone
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Email
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Date of Birth
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Male/Female
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Select One
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Employer
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Spouse/Partner’s Full Name
First Name
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Work Phone
Cell Phone
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NEAREST LIVING RELATIVE **(SOMEONE OTHER THAN YOUR SPOUSE/PARTNER)**
Name
Relationship to Patient
Home Phone
Cell Phone
Who Referred You?
Who Is Your Primary Care Physician?
Were you in an automobile accident in the last 12 months?
If so, when?
With whom may we discuss your medical information (i.e. spouse, children, friend, other relative)?
The law requires that we provide to the patient a copy of our Notice of Privacy Practices for health information. By signing below, the patient acknowledges receipt of such, or if you are the patient’s legal representative or authorized agent, you acknowledge receipt of such.
Patient Signature:
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