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Family
Nurse Midwife Associates
520 Jefferson
Avenue, Fifth Floor, Suite 506 * Jeannette, PA 15644
Office: 724-527-9159
* Fax: 724-527-9409
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PATIENT
REGISTRATION FORM
Welcome
to our practice!!! Please take the time to fill the form out
for us. If your information should change at future visits to
our office, please let us know so we can update your file. Thank
You!
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Name
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Phone
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Address
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Social Security
Number
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Date of Birth
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Your Email
Address
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| Your Insurance Information |
Family Physician
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Pharmacy
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If we cannot
reach you, do you have an alternate address or phone ?
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How did you
hear about our office ?
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Consent |
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I, |
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consent to a physical exam in the office of the |
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ordering
of laboratory tests as indicated by the nurse midwife or physician.
The nurse midwife has my permission to discuss my medical record
with a consulting physician if she deems consultation is necessary. |
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