Primary Doctor |
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Have you ever been to our office before? |
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HIV/Positive? |
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Check special circumstances |
UNDER 24 Years of Age Incarcerated Past 6 Months
Other Special Circumstances:
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Known illnesses |
Other Illnesses:
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Last time in Emergency Room |
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Mental health diagnosis |
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Please check any immediate needs you have |
Hepatitis C Test |
HASA/PA Help |
HIV Test |
Advocacy Groups |
Counseling |
Adherence Help |
Medicaid |
Medication |
SSI/SSD
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Rent Assistance |
Legal Help |
Emancipation Assist |
Detox
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Drug Treatment |
Food/Pantry |
Appointment Escort |
Income Assist |
Housing Help/Eviction |
Other |
Medical Care/Doctor |
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Medicaid Number: |
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Other Insurance |
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Please indicate/describe in detail anything else about your health history that you think would be useful or important for us to know: |
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