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CLIENT TREATMENT UPDATES
PLEASE FILL OUT THE FORM BELOW TO LET US KNOW ABOUT ANY OF YOUR RECENT TREATMENT UPDATES. IF YOU WOULD LIKE TO EMAIL ME DIRECTLY, I CAN BE REACHED VIA EMAIL:
medicalrecords@leavittmeunier.com
Medical Records Supervisor
Ryan Bell
504-834-2075
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* Indicates required question
CLIENT NAME
*
Your answer
Name of Your Doctor/Facility ?
*
Your answer
Address of facility (please include floor/suite)
*
Your answer
ONLINE PATIENT PORTAL LOGIN? (USERNAME/PASSWORD)
Your answer
Phone number of DR/FACILITY (IF YOU'RE UNSURE, LEAVE BLANK)
Your answer
WHEN WAS YOUR FIRST VISIT?
*
MM
/
DD
/
YYYY
WHEN WAS YOUR MOST RECENT VISIT?
*
MM
/
DD
/
YYYY
DO YOU HAVE ANY FOLLOW UP OR FUTURE VISITS WE SHOULD KNOW ABOUT?
MM
/
DD
/
YYYY
WHAT CONDITIONS RELATED TO YOUR DISABILITY ARE THEY TREATING? WHAT HAPPENED AT YOUR LAST APPOINTMENT?
*
Your answer
DID YOU HAVE ANY TESTS DONE OR DID THE DOCTOR ORDER ANY TESTS?
Your answer
WERE YOU PRESCRIBED ANY NEW MEDICATIONS? ANY SIDE EFFECTS YOU ARE HAVING?
Your answer
ADDITIONAL COMMENTS/CONCERNS/QUESTIONS?
Your answer
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