Patient Check-In Format

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Please take a moment to complete this check-in form with your most up-to-date and accurate information. The details you provide will help us ensure proper care during your visit and keep your medical records current. Your cooperation is essential in helping us deliver the best possible care tailored to your needs.

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I. PATIENT INFORMATION

• Full Name:                                                             

• Date of Birth:                           

• Age:              

• Gender:

• Address: ________________________________________

• City/State/ZIP: __________________________________

• Phone Number: __________________________________

• Email: ____________________________________________

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II. EMERGENCY CONTACT INFORMATION

• Name:                                                                          

• Relationship:                                                               

• Phone Number:                                                            

• Alternate Phone:                                                          

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III. INSURANCE INFORMATION (if applicable)

• Primary Insurance Provider: ___________________________

• Policy Number: ________________________________________

• Group Number: ________________________________________

• Insurance Phone Number:                                              

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IV. REASON FOR VISIT

Briefly describe the reason for your visit today:

                                                                                                                                                  

                                                                                                                                                  

When did your symptoms begin?:

                                                                                                                                                  

                                                                                                                                                  

Have you received treatment for this condition before?

• Yes

• No

If Yes, please explain: _________________________________

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V. MEDICAL HISTORY

Do you have any of the following medical conditions?

• Diabetes

• Hypertension (High Blood Pressure)

• Heart Disease

• Asthma

• Kidney Disease

• Cancer

• Other: _____________________________________________

Are you currently taking any medications?

• Yes

• No

If Yes, please list: ____________________________________

Any known allergies (e.g., medications, foods, etc.)

• Yes

• No

If Yes, please list: ____________________________________

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VI. CONSENT AND SIGNATURE

By signing below, I confirm that the information provided is accurate to the best of my knowledge.

Signature:

Date:                           

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