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Appointment Details:
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Select Nurse Name:
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List Other Nurse (if applicable):
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Activate Patient Demographics:
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Select Chief Complaint:
• • •
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List Other Complaint (if applicable):
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Select Prescribing Provider:
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List Other Prescribing Provider (if applicable):
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Medical History:
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Select Medical History:
• • •
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List Other Medical History (if applicable):
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List Current Medications:
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No changes have been made to medications since previous treatment.
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Currently taking any hormones?
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Select Allergy Status:
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List Specific Allergies (if applicable):
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Patient Consent Forms:
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Sign Informed Consent for IV Therapy:
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