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Type of form: Registration and history form
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250 per pack
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Size: 8 1/2″ x 11″
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Binding type: Loose
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Number of parts: 1
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Help ensure reimbursement and improve risk management
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Collects printed name and relationship to patient
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Medication lists requests correlating diagnosis
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Screens for artificial heart valves, artificial joints, heart murmur, mitral valve prolapse and pacemaker



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