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Available Forms

#3 NEW PATIENT Health History form

Instructions

This health history form is for new patients for their initial visit. This information is securely imported into your chart.

Health History

MM/DD/YYYY
check all that apply
please type none if applicable
please describe any serious injuries
please list any medications or supplements you are taking with dose and frequency
Please list any allergies (penicillin, trees, nuts, etc)
check all that apply

THANK YOU! Please click "Submit Form" to send to Village Family Clinic.

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