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Piedmont Regional Feeding & Orator Clinic, LLC P.O. Box 10566 Danville, Virginia 24543 Phone (434) 7997732 Fax (434) 7997733 Patient Information Patient Name: Age: Date of Birth: Sex: Primary Concern:
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01
Visit our website and locate the "Patient Information" section.
02
Click on the corresponding link or button to access the form.
03
Download the form onto your computer or device by clicking on the download icon.
04
Open the downloaded file using a PDF reader or any other compatible software.
05
Fill in all the required information accurately and thoroughly.
06
Provide personal details such as your name, contact information, and date of birth.
07
Answer any medical history questions or inquiries about pre-existing conditions.
08
Include any allergies or medications that you are currently taking, if applicable.
09
Provide emergency contact information in case of any unforeseen circumstances.
10
Once you have completed filling out the form, save it on your device.
11
Review the information you have provided to ensure its correctness and completeness.
12
Finally, submit the filled-out form to the relevant recipient as specified on the website or in any accompanying instructions.
Anyone who requires medical services or treatment from our facility may need to download our patient information form. This form is essential for documenting your medical history, ensuring accurate record-keeping, and enabling our healthcare professionals to provide the best possible care tailored to your specific needs. By filling out this form, you contribute to the smooth and efficient delivery of healthcare services.
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