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Benjamin Hawes, MAOM, Lic. Ac. 1 West 1st StCortez, CO 81321970.565.0230PATIENT INFORMATION |
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DATE:_____________________ |
NAME: _________________________________________________________ |
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MALE ٱ FEMALE ٱ |
OCCUPATION:______________________________________________ |
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DATE of BIRTH :__________________ |
PLACE of BIRTH:_____________________________ |
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TEL. #: WORK:_______________________________ |
HOME:_______________________________________ |
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ADDRESS:_____________________________________________________________________________ |
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CITY_________________________________ |
STATE:__________________ |
ZIP:_______________ |
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E-Mail Address (optional) _________________________________________________ |
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PRIMARY CARE PHYSICIAN:______________________________________________ |
TEL. #: __________________ |
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SPECIALIST PHYSICIAN:___________________________________________ |
TEL. #: ____________________ |
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SPECIALIST PHYSICIAN:___________________________________________ |
TEL. #: ____________________ |
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EMERGENCY CONTACT:__________________________________________ |
TEL. #: ____________________ |
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RELATIONSHIP:____________________________________________ |
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HAVE YOU RECEIVED ACUPUNCTURE / CHINESE HERBS / ORIENTAL MEDICINE IN THE PAST? Y / N |
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IF YES, BY WHOM?_____________________________ |
FOR WHAT CONDITION?______________________ |
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HOW DID YOU HEAR ABOUT THIS OFFICE?_______________________________________________________ |
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REFERRED BY:________________________________________________________________________________ |
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