Patient Registration application for Dr Nguyen

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Patient Registration Application for Dr Nguyen

Patient application form

Please complete this form if requesting a new Family Doctor

3.*Dates of birth(s)?

4.*Phone numbers? Home and work? email address?

5.Why do you need a new doctor?

I have moved to this area
My doctor has relocated
My doctore has retired
I am dissatisfied with my GP
Other reason

6.What medical conditons do you have?

7.What medications do you use currently?

8.*What is your primary language of communication?

9.*How would you describe your health care focus?

emphasis on diet
emphasis on exercise
quitting smoking
reducing alcohol usage
concern re medication usage
worried about family history

10.Are you interested in electronic communication if feasible about your health care? Can we use email as a main source of communication?



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