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Preferred Language:
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Do You Smoke? (Turn the switch to ON if you smoke)
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Do You Drink? (Turn the switch to ON if you drink)
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1. Allergies
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Medications Patient Is Allergic To:
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Amoxicillin
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Aspirin
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Azithromycin
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Clarithromycin (Biaxin)
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Ciprofloxacin
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Codeine
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Doxycycline
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Erythromycin
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Ibuprofen (Advil, Motrin, Midol, Tylenol)
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Iodine
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Lidocaine
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Morphine
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Naproxen (Aleve)
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Sulfonamide
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Tetracycline
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Others
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Please Indicate Any Other Known Allergies:
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Eggs
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Latex
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Soy
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Nuts
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Peanuts
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Fish
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Milk & Dairy
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Wheat
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Garlic
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Other(s)
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2. Patient Current Medications
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Please check any medications that the patient is currently taking:
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Amoxicillin
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Aspirin
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Azithromycin
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Clarithromycin (Biaxin)
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Ciprofloxacin
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Codeine
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Doxycycline
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Erythromycin
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Ibuprofen (Advil, Motrin, Midol, Tylenol)
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Iodine
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Lidocaine
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Morphine
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Naproxen (Aleve)
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Sulfonamide
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Tetracycline
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Other(s)
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3. Patient Medical Conditions:
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Please check any medical conditions that the patient has been diagnosed with:
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Acid reflux
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Asthma
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Blood clots
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Cancer
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Cholesterol
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Coronary artery disease (CAD)
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Diabetes
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Heart attack
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Hypertension
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Kidney disease
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Stomach ulcer
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Stroke
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Thyroid disease
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Other(s)
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4. Patient Past Medical Procedures:
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Please select which medical procedure patient has undergone
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Angioplasty
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Appendectomy
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Back surgery
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Gallbladder surgery
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Heart bypass
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Hernia repair
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Hip replacement
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Knee surgery
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Pacemaker
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Tonsillectomy
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Vasectomy
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Other(s)
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5. Patient Family Medical History:
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Please select which conditions a family member has been diagnosed with:
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Alzheimers
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Asthma
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Cancer
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Coronary artery disease (CAD)
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Diabetes
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Heart attack
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High Cholesterol
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Hypertension
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Kidney disease
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Migraines
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Osteoporosis
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Seizure
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Stroke
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Other(s)
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Patient’s Preferred Pharmacy:
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Pharmacy Name:
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Phone Number:
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Address:
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Patient’s Preferred Payment Method:
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Card Type:
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Name On Card:
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Card Number:
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Expires:
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CVV:
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Billing Address:
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