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New Patient Information Name: Primary Language: Drug Allergies, if any: Race: Primary Care Physician: Birth Date: Home Phone: Ethnicity: Cell Phone: Address (Street / City / State / Zip): Employer:

How to fill out etsu obgyn - 0101

How to fill out ETSU OBGYN - 0101:

1. Begin by gathering all necessary information and documents needed to complete ETSU OBGYN - 0101. This may include your personal information, medical history, and insurance information.
2. Fill out the "Personal Information" section of the form, providing your full name, date of birth, current address, and contact information.
3. In the "Medical History" section, provide detailed information about any previous or current medical conditions, surgeries, allergies, and medications you are currently taking.
4. If applicable, provide information about your pregnancy status, including the number of pregnancies and any complications you may have experienced.
5. In the "Insurance Information" section, provide details about your insurance coverage, including the name of your insurance provider, policy number, and primary insured individual.
6. Review the form carefully to ensure all information provided is accurate and up-to-date. Make any necessary additions or corrections.
7. Sign and date the form to certify that all information provided is true and accurate.
8. Submit the completed ETSU OBGYN - 0101 form to the appropriate department or healthcare provider.

Who needs ETSU OBGYN - 0101:

1. Women seeking obstetrics and gynecology services at East Tennessee State University (ETSU).
2. Individuals who require specialized care during pregnancy, childbirth, or for gynecological conditions.
3. Patients who wish to establish a relationship with an obstetrician-gynecologist at ETSU's OBGYN department for ongoing care and treatment.

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