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Get GA Gastroenterology Personal History Established Patient - Atlanta City 2018-2024

Date of Last Office Visit Name Age Primary Care Physician Date of Birth Referring Physician 1) Describe the reason(s) for your visit today 2) Preferred Pharmacy Name Pharmacy Address Pharmacy Phone Street Suite # City State Zip Yes I authorize Atlanta Gastroenterology Associates to obtain my prescription history electronically. No 3) Tobacco (cigarettes, cigars, chewing tobacco) Never Former Current (Every Day) Current (Some Days) Current (Unknown) Lis.

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