Medical Intake

Who is the patient?

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Who are you?

Reason for Exam

Attach Photos or Files (optional)

You may also fax documents to us at 919-924-0275
Please list all drops, oral medications, topicals, inhalers.
Has your child been diagnosed with any medical condition?
All past surgeries of any kind, anywhere on the body, with year it was done.
If no, please list number of weeks at birth.
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