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Initial Patient Record
For children more than 1 month old

Step #1

INITIAL PATIENT RECORD




PAST MEDICAL HISTORY


 































Immunization Record


 


If yes, please bring a copy of immunization record to the appointment and be ready to give to receptionist.


List medications taken by child at present

Name and Dosage (If dose unknown, please list pharmacy where prescription was filled so we may call if needed)
Please include all oral, inhaled, nasal, injectable, herbal, vitamins, and over-the-counter medications


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