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M5. 002A LAKE HOUSTON PHYSICAL THERAPY MEDICAL HISTORY FORM PATIENT NAME TODAY S DATE REFERRING PHYSICIAN S NAME DATE OF INJURY OR ONSET PRIMARY CARE PHYSICIAN S NAME ARE YOU PRESENTLY WORKING Y ES NO CAUSE OF INJURY OR ONSET DATE OF NEXT MD APPT DO YOU CURRENTLY HAVE ANY FLU TYPE SYMPTOMS I. Attachment B1. 003A PATIENT INTAKE AND CONSENT FORM Internal Use Only A/C Name First Name MI A/C Type Office Date of Injury/Onset Today s Date Last Name Date of Birth Age Address Sex oM oF Marital Status...
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Step 1: Start by reading the raintree intake amp consent form carefully.
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Step 2: Fill out your personal information, such as your name, date of birth, and contact details.
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Step 3: Provide information about your medical history, including any current medications or conditions.
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Anyone who is seeking medical care or services at the raintree facility needs to fill out the raintree intake amp consent form.
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Raintree intake amp consent is a form that collects necessary information from individuals before they can receive services or participate in programs.
Individuals who are seeking services or participating in programs that require this form to be completed are required to file raintree intake amp consent.
To fill out raintree intake amp consent, individuals must provide accurate information about themselves and any relevant details based on the requirements of the form.
The purpose of raintree intake amp consent is to ensure that individuals provide necessary information and consent before receiving services or participating in programs.
Information such as personal details, contact information, medical history, and consent for treatment or program participation must be reported on raintree intake amp consent.
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