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Available Forms

Patient Registration Form

***THIS FORM IS ONLY FOR DR. KARTCHNER'S PRACTICE IN TUCSON, ARIZONA. *** Please take a moment to provide your health history. Don't worry if a question doesn't apply to you or if you don't understand a question. We will be able to review this in person.

We do not submit claims to insurance company. We do not accept cash or check at this time.

Emergency Contacts

Medical History

Please write down any vitamins, over-the-counter medications, herbal supplements, and anything else you take regularly.
Please write down any allergies and their reactions.
This includes cigarettes, cigars, electronic cigarettes, hookah, dip, or any other tobacco products.
Please indicate if you have ever had any of these conditions.
Please add any important medical history we may have missed.
Please indicate surgery and year
Please indicate any health conditions present in your family
Please indicate any family history we may have missed.

Other Health Care Providers

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