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Cardiology
Cardiovascular and Thoracic Surgery
Endocrinology
Family Medicine
Gastroenterology
General Surgery
Geriatric Medicine
Internal Medicine
Neurology
Neurosurgery
Obstetrics and Gynecology
Orthopedic and Spine Surgery
Pain Medicine
Urgent Care
Urology
Vascular Surgery
Weight-Loss Surgery
Locations
Texoma Cardiovascular Care Associates
Texoma Cardiovascular Surgeons
Texoma Heart Group
Texoma Heart Group (Durant)
TexomaCare Endocrinology at Denison
TexomaCare Family Medicine at Denison (Suite 225)
TexomaCare Gastroenterology at Denison
TexomaCare Internal Medicine at Denison (Sanders-Truly-Watkins)
TexomaCare Internal Medicine at Denison (Balch-Bheemanathi-Ohnes)
TexomaCare Internal Medicine at Denison (Landrum)
TexomaCare Neurology at Denison
TexomaCare Gyn at Denison (Parker)
TexomaCare Ob/Gyn at Denison
TexomaCare-Orthopedic and Spine Surgery
TexomaCare Surgery at Denison
TexomaCare Bonham
TexomaCare Durant
TexomaCare Family Medicine at Denison (Suite 300)
TexomaCare Family Medicine at Sherman (Restrepo)
TexomaCare Family Medicine at Sherman (Vallejo Nieto)
TexomaCare Madill
TexomaCare Neurosurgery at Denison
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Patient Information and Medical Screening Form Spanish
UHS Digital
2023-08-01T15:25:49-04:00
"
*
" indicates required fields
Formulario de información del paciente
Nombre
*
First
Apellido
Fecha de nacimiento:
*
SSN:
Sexo:
Direccion
Street Address
Ciudad
Estado
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Estado
Codigo Postal
Number telefono
Cell
Casa
Trabajo
Razon por la consulta:
Parte responsible (si es menor de edad, incluya decha de nacimento y relacion)
Nombre
First
Apellido
Fecha de nacimiento:
Relacion al paciente:
Seguro
Seguro medico (si no tiene seguro, escriba N/A):
*
Identificacion de miembro:
Grupo #:
Doctor primario:
Historial Medico
Detalle sobre cualquier diagnostico medico o condiciones cronicas de salud:
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Lista de medicamentos: Todos los medicamentos actuales recetados por doctor/vitaminas/hierbas/suplementos
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Frequencia (#por dia)
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