Basso Foot and Ankle Clinics
Welcome to our practice! Please complete the following intake form.
Name
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Last Name
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Year
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Address
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Insurance Card (Front)
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Emergency Contact Information
Medical History
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What is your HgbA1c?
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Primary Care Physician
Preferred Pharmacy
List all current medications
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Prior surgeries
Weight
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Average # alcoholic drinks per week?
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0 -1 package a day
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