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Medi-Card
To assist DeKalb Medical and other healthcare providers in delivering the best care possible, fill out this form with all of your pertinent medical information and keep it with you at all times.  Please be sure to share this information during your regularly scheduled office visits, and make sure someone else knows where it is kept in case of an emergency.


Name:
Date of Birth:
Home Phone:
Cell Phone:
Medication Dosage (mg) Times per Day?
Vaccines (Date) [EX: 01/01/2010]
Flu:
Pneumonia:
Tetanus:
Allergies Reaction

SURGICAL HISTORY
Procedure Date
Medical conditions for which I am being treated:
Do you have a(n):

Healthcare Agent Name:
Phone:

Other Emergency Phone #s:
Name:
Relation:
Phone:
Name:
Relation:
Phone:
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DeKalb Medical, 2701 North Decatur Rd., Decatur, GA 30033 | For General Information: 404.501.1000 | For Patient Inquiries: 404.501.5200

 
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