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Encrypted Form for Personal Health Information

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Please fill out as much of this form as you feel comfotable with. For returning clients you do not have to fill out all medical hisoty again if you have already done so.

This is an Encrypted form that we urge you to use when transmitting any personal health information to us. If you do not wish to use this form please email us a request to submit personal health information and we will send you a encrypted email that you can repy to. Both this form and our encrypted HIPAA email are provided by HushMail.

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Patient Information

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Primary Care Provider Info

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Medical History


If you have had a valve replacement which type of valve do you have?

Do you have a feeding tube?

Are you on oxygen?

Do you have a pacemaker or ICD?


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Team Uncle Joe

Telephone:+1 530 591 2890