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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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Select Prescribing Provider:
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List Other Prescribing Provider (if applicable):
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Activate Patient Demographics:
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Select Chief Complaint:
• • •
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Specific Chief Complaint
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Medical History:
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Select Medical History:
• • •
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List Current Medications:
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List Other Medical History (if applicable):
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No changes have been made to medications since previous treatment.
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Select Allergy Status:
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List Specific Allergies (if applicable):
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Heparin Allergy
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Provider Consultation Note
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Patient Protocol:
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General Wellness/Prevention
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Sport Performance
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Acute Pathogenic
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Acute Non-Pathogenic
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Chronic Pathogenic
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Chronic Non-Pathogenic
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Pre-Conditioning
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