GreenStar Patient Intake Form
General Information
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Medical Information
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Female Patients


If yes, then







If yes, give dates and details below

If yes, give dates and details below
Please indicate if you or your immediate family members have had any following problems
Please indicate if you have had any of the following symptoms consistently:


Signature
I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I
am not a member, employee or agent of any media or law enforcement agency. It is illegal for a patient to film or record in this
office with video camera, cell phone or any other recording device whether still image, video or audio. This is a direct violation
of HIPAA regulations and Patient/Doctor confidentiality.
I am aware that my approval or recommendation may be revoked at any time if I have perjured or misrepresented myself or my
condition.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT