Contact 1 — Open Hands DPC

Now that you belong…help us get to know you!

Complete this form SEPARATELY for each member in your family*.

Emergency Contact

Name

First Name

Last Name

Date of Birth

Gender

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical History

Anything for which you take Rx, OTC medications, vitamins or alternative therapies.

Hospital/Surgical History

Any hospitalizations or surgeries you have had

Medications

Any Rx, OTC, Vitamins, Alternative Therapies you use at least once a month.

Social History

Marital status. Employment. Habits (exercise, dietary choices, caffeine, tobacco use, alcohol intake). Sexual Orientation.

Allergies

List allergy and symptoms

Preferred Pharmacy

Name, phone number, address

Preventive Medical History

Vaccinations. Procedures/Imaging

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