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Get AFC Urgent Care Patient Registration Form 2015

completely. See Notice of Privacy Practices. Is today’s visit work related? If yes: Do not complete this form. Please see front desk staff for instructions. Patient’s Full Name: Date of Birth: Sex: o M Social Security #: o F REASON FOR VISIT: Street Address /Apt #: City, State, Zip: Home Leave message: Phone: Was this the result of a motor vehicle accident? o Yes o No Home Email Address: Work Phone: Confidential Email Address: Best form of contact? o Home Emergen.

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