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85 Manchester St. Concord NH 03301 603. 229. 0021 Electronic Health Records Intake Form This form complies with CMS EHR incentive program requirements First Name Last Name Email address Preferred method of communication for patient reminders Circle one Email / Phone / Mail DOB // Gender Circle one Male / Female Preferred Language Smoking Status Circle one Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked Smoking Start Date Optional Family Medical History Record one diagnosis...
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