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This is a medical release form. This medical release form will allow you to authorize another person to receive medical information about you from your healthcare provider.
Please complete the following questions to the best of your ability. If you have any questions, please feel free to ask your provider or call our office.
Why are you seeking medical treatment at this time?
Have you ever been diagnosed with any medical conditions? If so, please list them.
Do you have any allergies? If so, please list them.
Are you currently taking any medications? If so, please list them.
Have you ever had any surgeries? If so, please list them.
Do you have any family history of medical conditions? If so, please list them.
Do you have any personal history of medical conditions? If so, please list them.
Are you pregnant or nursing?
Do you have any other medical conditions that we should be aware of? If so, please list them.