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Patient Intake Form

Patient Information

Birthday
Month
Day
Year
Gender
Multi-line address

Emergency Contact

Insurance Information

Holder DOB:
Month
Day
Year

Medical History

Please check any conditions you currently have or have been treated for in the past:

Surgical History & Hospitalizations

Please list any past surgeries or major hospitalizations and the approximate dates:

Date
Month
Day
Year
Date
Month
Day
Year
Date
Month
Day
Year

Medications & Allergies

Current Medications

List all prescription medications, over-the-counter drugs, vitamins, and supplements you

currently take:

Allergies

List any allergies to medications, food, or environmental factors, along with your reaction:

Social & Family History

Tobacco Use:
Alcohol Use
Family History: Please note if parents or siblings have history of:

Acknowledgment & Signature

By signing below, I certify that the information provided on this form is accurate and complete to the best of my knowledge. I

authorize Healthy Living First Medical Group to provide medical treatment and to submit claims to my insurance provider for

services rendered.

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Date
Month
Day
Year
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