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Please fill in additional patients.
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Abscess
Animal Bite
Body Injury (Leg, Arm, Finger, Toe etc)
Body Pain (Head, Arms, Legs, Back, Etc)
Burn Treatment/ Wound Care
Car Accident
Ear Pain/Aches
Flu/Covid Symptoms
Illness
Lab Work
Laceration/ Removal
Medication Refill
Pregnancy Related
Pre-Employment Physical
Shortness of Breath/ Asthma
Sports Physical
TeleHealth
TB Test
Urinary Symptoms
Work Related Injury
Work Note
Tooth Pain
The clinic has reached its limit for this visit reason today.
Patient First Name
Patient Last Name
Patient Type
Patient Type
New Patient
Existing Patient
Date of Birth
Patient Birth Sex
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Please provide any additional symptoms or information which would help us in diagnosing and treating your issue.
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Cell Phone Number
minutes before your visit
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