Please fill out both sides of this form and bring it with you 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering today's date at the top of the form. This helps keep your records organized.
3. Fill in your personal information, including your name, age, date of birth, and primary care physician. Ensure accuracy for effective communication.
4. In the 'Reason for Visit' section, describe why you are attending the appointment today. Be as detailed as possible to assist your healthcare provider.
5. Complete the pharmacy information section, including name, address, and phone number. This is crucial for prescription management.
6. Indicate your tobacco use status and list any allergies or current medications. This information is vital for your treatment plan.
7. Answer questions regarding symptoms you may be experiencing by checking 'Yes' or 'No'. Provide descriptions where necessary.
8. Sign and date the form at the bottom to confirm that all information provided is accurate before bringing it to your appointment.

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