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Get Patient Name: Account Number:

Medical History Form Patient Name: Account Number: Height: ft in Weight: (pounds) Date of injury: Diagnosis as stated to you by your physician: How did this injury/ exacerbation occur? Have you been.

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  2. Open the form in our online editing tool.
  3. Look through the recommendations to find out which info you have to provide.
  4. Click on the fillable fields and add the necessary details.
  5. Put the relevant date and insert your e-signature when you complete all of the boxes.
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  8. Send the e-form to the parties involved.

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