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Welcome to Modern Health
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Patient Intake Demographics
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Patient First, Last Name
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Parent or Guardian
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DOB (Date of Birth)
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Gender at Birth
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Address (Street)
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City
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State
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Zip
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Phone Number
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Email
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Marital Status
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Pronouns
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Emergency Contact (Name)
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Emergency Contact (Phone Number)
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Emergency Contact (Relation)
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Employer (Name)
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Employer (Address)
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Employer (Phone Number)
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Drug Allergies
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Current Medication's
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Smoking Status
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Recreational or Non-Prescribed Substance Use
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Do you currently use, or have you previously used, any of the following substances?
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Do you consume alcohol?
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If Yes (How often do you drink?)
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If Sober (When was your last drink?) Date
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Preferred Pharmacy (Name and Address)
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Where did you hear about us?
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Patient Consent for Text, Email, Voice Messaging & Other Healthcare Communications
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Patient Consent
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I have consent to receive text messaging.
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I give consent to receive email communications
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I understand it is my responsibility, and agree to, keep my mobile number up to date.
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I understand attending and canceling my appointments is still my responsibility.
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I understand the security of email/text messaging cannot be guaranteed and accept the risk.
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I understand that this consent will apply to future appointment reminders, health information, and other communications unless I request to stop the service in writing.
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