ATTENDING PHYSICIAN'S STATEMENT

THE FOLLOWING PATIENT WAS TREATED AT THIS CLINIC:

PATIENT'S NAME:  

DATE OF BIRTH:

DATE OF ILLNESS (FIRST SYMPTOM) OR INJURY:
IS CONDITION DUE TO PREGNANCY? YES  NO
DATE OF FIRST CONSULTATION FOR THIS CONDITION:
OTHER PRIOR DISEASES AFFECTING PRESENT CONDITION:
HAS THIS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? YES  NO
IF YES, APPROXIMATE DATE AND PLACE:
IF YES, DID PATIENT RECEIVE ANY TREATMENT FOR PRIOR SYMPTOMS?
DATE OF TREATMENT: OUT PATIENT  HOME VISIT
FROM: TO:  DATE: 

PROCEDUREDATE OF SERVICECHARGES
OFFICE VISIT
TOTAL 

PAID BY:  

ATTENDING PHYSICIANS: