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Get Digestive Disease Association Patient History

Tely so that we may obtain the necessary information for our files and background information on your medical problem. In this way, more time will be available for you to talk to the doctor at the time of your visit. All information is held in strict confidence and will NOT be released to anyone without your written consent. PATIENT INFORMATION-Please print all information Patient ID Number: (for office use) Date: Referring Physician: Primary Care Physician: Phone Number: ( Name: ) Date.

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