Fillable Formulario de informacin del paciente (City of Midland Texas)

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Formulario de informacin del paciente (City of Midland Texas)

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The Formulario de informacin del paciente (City of Midland Texas) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of Midland Texas

BROWSE CITY OF MIDLAND TEXAS (TX) FORMS

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3303 West Illinois Suite 22
Midland, TX 79703
Teléfono 432-681-7613
Formulario de información del paciente
Nombre del Pacient
Fecha de Nacimeinto
Genero
Direccion
Apt #
Ciudad
Estado
Codigo Postal
# deTelefono
Escribe el nombre complete de la madre
Apellido paterno de la madre
Fecha de nacimiento de la madre
¿Lo han visto en el Departamento de Salud de Midland antes de hoy?
☐
Si
☐
No
¿Cuál es el propósito de su visita hoy? Marque las casillas a continuación.
☐Vacunas ☐Prueba de TB ☐Resultados de TB ☐Prueba de ebarazo
☐
☐
Prueba de ETS
1, 2
☐
Resultados de ETS
☐
Prueba de VIH
☐
Resultados de VIH
1: Los hombres no usan el baño hasta que se complete la ETS.
2: Las mujeres no pueden hacerse la prueba si actualmente tienen el período
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Formulario de informacin del paciente (City of Midland Texas)

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Completed 23 January 2021

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