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Voytik Center for Orthopedic Care
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Pre appointment info
Pre appointment info
Form Date
Pre-Visit History
Information
Had flu shot in the last year
Had pneumonia shot in the last year?
Do you smoke?
Are you over 50?
Have you had a colonoscopy?
Reason For Visit
Tell us in a few lines what we will be treating you for.
Was this due to an accident?
-- Please Select --
Yes
No
If yes, is there an attorney involved?
-- Please Select --
Yes
No
Name
*
Date of Birth
Phone Number
*
* Required field
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