Email: [email protected]

Web: https://quickprimarycare.org/

Quick Primary Care

8550 SW State Road 200
Ocala, FL 34481

Phone: 352-854-9110

Fax: 352-854-9119

QPC New Patient - Page 2

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Quick Primary Care

Patient History (Allergies, Medications)

Today's Date *

Full Name *

IF YOU DO NOT HAVE ANY OF THE FOLLOWING, PLEASE PROVIDE THE NAME AND PHONE NUMBER

Pharmacy 1

Pharmacy Name

Phone Number

Address/Location of this Pharmacy

Pharmacy 2

Pharmacy Name

Phone Number

Address/Location of this Pharmacy

Pharmacy 3

Pharmacy Name

Phone Number

Address/Location of this Pharmacy

Pharmacy 4

Pharmacy Name

Phone Number

Address/Location of this Pharmacy

Pharmacy 5

Pharmacy Name

Phone Number

Address/Location of this Pharmacy

Current Prescription Medications

Current Prescription Medications

Over the Counter Medications

Over the Counter Medications

Medical Drug Allergies

Medical Drug Allergies

Food Allergies

List of Allergies

Symptoms

List of Symptoms

Herbal/Vitamins

Herbal/Vitamins

Signature

Signature *