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  • New Patient Intake

    Please complete this health history questionnaire to the best of your abilities. Dr Alexis Alexandridis will review your responses. Your Protected Health Information is secure on this intake form. If you do not have an appointment yet, please visit dralexissurgery.com and click on the "Schedule an Appointment" link.
  • Personal Information

    Contact Info, Demographics, Emergency Contacts
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  • Your Health Information

    Past Medical and Surgical History
  • Your Health Habits

    Social History
  • Your Family Medical History

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  • Review of Systems

    Please check if you a CURRENTLY having trouble with any of the following: (Check all that apply)
  • Thank you! Now, here is the fine print...

    Please take a moment to review the policies below and indicate your acceptance. You do not need to print these forms. Your e-signature below indicates that you have READ the policies and ACCEPT the terms, including our "No-show"/cancellation FEES and billing/collections policies. ***Ensure all items with a red asterisk are completed to complete your intake form.***
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