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Patient Demographic Form - PDF

Patient Demographic Form - PDF 2025

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The document is a comprehensive Patient Intake Form used by Elica Health Centers, which collects essential personal, socio-economic, and health-related information from patients. It includes sections for patient demographics, emergency contacts, insurance details, consent for treatment, privacy acknowledgments, and specific health histories for both adults and minors. The form aims to gather necessary data for medical care while ensuring compliance with federal regulations regarding patient information confidentiality.

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