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Emergency Contact Info:
Emergency Contact Name
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Emergency Contact Relationship: SiblingParentChildfamilyfriendlegal Guardian

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Only In ER: YES
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Insuance Company1:
Insuance Policy 1:
Insurance Company 2:
Insurance Policy 2:

Medical Problems:

Surgical History:

Day Surgery / Procedures:

Inatvie Medical Problems:




Pharmacy Name:
Pharmacy Tel:
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I have read , understood and agree to the HIPPA, release of information, Billing , Appointments, Drug testing , Labs policy and procedure of the practice. I understand these policies may change and its my responsibility to request updates. I also understands that I can be discharged with 30 days notice. Info given is correct, any incorrect information may lead to inappropriate care and harm. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize DOCTOR IS IN, CORP / HASSAN FAROOQ, MD, or insurance company to release any information required processing my claims.

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