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Input Form:Deal with this potential dealer,buyer,seller,supplier,manufacturer,exporter,importer
(Any information to deal,buy, sell, quote for products or service)
Authorization to Use or Disclose Protected Health Information Patient . . . Three Rivers Family Medicine, PSC Authorization to Use or Disclose Protected Health Information Patient name: _____ Date of birth: _____ Previous name: _____ I My Authorization: TRFM, PSC may use or disclose the following health care information
Three Rivers Family Medicine – Providing exceptional care for . . . Three Rivers Family Medicine, PSC To Parents and Guardians of Minor Children The providers and staff of Three Rivers Family Medicine, PSC place great emphasis on the health and well being of each and every patient in our clinic and we appreciate that you have entrusted us to provide health care services to your minor child
Health Screening Questionnaire - 3riversmedicine. com (Include prescriptions, vitamins, birth control pills and over the counter medicine) Do you have any family history of : rdiabetes rglaucoma rhypertension rthyroid disease rheart disease rhemachromatosis rbreast, colon or prostate cancer rother cancers specify:_____ PART 5 - HEALTH MAINTENENCE For OfficeUseOnly