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R×HMC95rHALIFAX HEALTH PATIENT ASSISTANCE 303 N. Clyde Morris Blvd., Daytona Beach, FL 32114 (386) 4254019Patient Name Adm. Date of Birth MR #Dr. Age Visit #VOL USIA/FLAGLER HOMELESS COALITION APPLICATIONName:___
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Obtain the Halifax Health Emergency Department form.
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Fill out the patient's personal information including name, date of birth, address, and contact number.
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List any medications the patient is currently taking.
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Sign and date the form before submitting it to the Halifax Health Emergency Department.
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Individuals experiencing a medical emergency or requiring urgent medical attention.
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Halifax Health Emergency Department offers medical care for patients in need of immediate attention.
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