Sewell Family Medicine.

Sewell Family Medicine. Sewell Family Medicine. Sewell Family Medicine.

Sewell Family Medicine.

Sewell Family Medicine. Sewell Family Medicine. Sewell Family Medicine.

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Suboxone Patients
VIVITROL PATIENTS
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Home
About Us
Contact Us
Forms
Suboxone Patients
VIVITROL PATIENTS

PERMISSION FOR MONTHLY FUNDS WITHDAWAL

Pre-Authorized Checking Account Withdrawal Form.

Name*

Email Address:*

Routing Number : *

Checking Account Number: *

By signing below, I agree to have Funds withdrawn on a Monthly basis.

Signature: *

Date:*

Registration Form

Name*

Email Address*

Address: *

Next of Kin:*

Home Phone:*

Cell Phone:

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Sewell Family Medicine.

Medical History:

Name*

Email Address:*

Medications with Dosage *

Past Medical History: *

Past Surgery: *

Social History: Smoker. Y. or N. *

Alcohol. How often *

DIP. Y. or N. *

Family History. Mother’s family.*

Family History. Father's Family. *

If over 50 have you had Colon screening?*

If male over 50, have you had Prostate screening such as a PSA?*

Allergies and What happened:*

Medical History Continued:

Name

Email Address:*

If Female over 35 have you had a Mammogram ?*

Any specific Needs or Concerns ?

Sewell Family Medicine.

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