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Scott L. Beals DO FAAD www. dermsurgctr.com Fax 850- 897-7547 Dsc1 derm-surg. com 4566 Hwy 20 E Suite 101 Niceville FL 32578 850 897-7546 184 E Redstone Ave Suite B Crestview FL 32539 850 398-8554 301 Medical Drive Suite B Andalusia AL 36420 334 222-7546 HISTORY AND INTAKE FORM Name Language English Other Gender M F DOB // Preferred Pharmacy Pharmacy Phone Pharmacy Address Primary Care Provider Phone Past Medical History Please circle all that apply Anxiety Depression Arthritis Diabetes...
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