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Confidential Medical History Form Please return your form to the Pharmacy when you have finished. The Pharmacist will meet with you to review your information. Thank you. Today's Date: Name:Birthdate:Age:Address:
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How to fill out please return your form:

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Once you have filled out the form completely and verified the accuracy of the information, please return your form as directed. This could involve submitting it online, mailing it to a specific address, or handing it in at a designated location.

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Remember, always carefully read and follow the instructions provided on the form to ensure your information is correctly filled out and promptly returned to the appropriate entity.
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