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MEDICAL INFORMATION

For: .....................................................................................

Prefered Hospital:....................................................................

In Emerg. notify:............................................Tele.#(.....)............

Medicare Number:.....-....-.......................

Other Ins.Co............................. ID#.......................

Primary Doctor:.......................... Phone:(...)...............

Specialist ":............................ Phone:(...)...............

Specialist ":............................ Phone:(...)...............

      Prescription Medications that I am CURRENTLY taking:

NAME Of Prescription      STRENGTH        DOSAGE (Taken when )

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            Over the Counter Medications I am Taking

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Special Notes: