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Patient Forms - Auburn Urogynecology and Women's Health

Patient Forms - Auburn Urogynecology and Women's Health 2026

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4.8 out of 5

150 votes

The document is a URO-GYN Women's Health Patient Intake History form that collects essential patient information, including personal details, social history, current medications, pregnancy history, allergies, medical and surgical history. It requires the patient's signature to certify the accuracy of the provided information.

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Click ‘Get Form’ to open the Patient Forms - Auburn Urogynecology and Women's Health in our editor.
Begin by entering your personal information, including your name and birthdate. Ensure accuracy as this information is crucial for your medical records.
Fill in the referring clinician's name and pharmacy details. This helps streamline communication regarding your care.
Indicate your primary language preference from the options provided. This ensures you receive information in a language you are comfortable with.
Complete the social history section by detailing your occupation and any tobacco or alcohol use. Be honest, as this information can impact your health assessments.
List all current medications, including prescriptions and supplements. If necessary, attach an additional sheet for more entries.
Provide details about your pregnancy history, allergies, and any existing medical conditions. This section is vital for understanding your health background.
Finally, review all entered information for accuracy before signing at the bottom of the form to certify its correctness.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (150 Votes)

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