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Place an X in the column corresponding the frequency and severity of each symptom. If you rarely have the symptom just leave that line blank. 5542 S. Flamingo Road Cooper City FL 33330 954 252-5454 Name Todays Date // NEW PATIENT HISTORY FORM M PLEASE LIST YOUR PRIMARY CARE PHYSICIAN NAME SPECIALTY CITY STATE DATE LAST SEEN LIST ANY OTHER PHYSICIANS YOU SEE WHY ARE YOU SEEING US TODAY MEDICAL HISTORY HAVE YOU OR MEMBERS OF YOUR FAMILY HAD ANY OF THE FOLLOWING CONDTIONS YOU FAMILY HIGH...
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Gather all required documents such as identification, proof of address, and any additional supporting documentation.
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Visit the official website of Cooper City, Florida and navigate to the forms section.
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