Take a few minutes to fill out this form, print it, and take it with you to the physician's office.Tip: There are only 5 lines available per question, so summarize information as much as possible. If you type more than 5 lines it won't show on the printout.
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Security Crossroads Medical Center. 2 East Rolling Crossroads #159, Catonsville MD 21228.
410-747-5888 Fax: 410-747-9648. www.securitycrossroads.com
Reason for your visit:
When did the problem start?
What makes the problem worse?
How have you tried to treat your condition?
List any medicines you've taken for the problem.
Are there any other issues that we need to address ?
Do you need any referrals ? Do you have to call your health plan to change your PCP ?
IMPORTANT : The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.
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