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Nextcare Reimbursement Form 2016-2023
Onset: ______ / ________ / ________
dd
mm
yyyy
What date did the Patient first feel same / similar symptom(s): ______ / ________ / ________
dd
Is the Patient under any type of treatment / Meds:
If yes, indicate what assessment and since when:
mm
yyyy
☐YES ☐ NO
OBJECTIVE / ASSESSMENT (To be completed by Physician)
Past Medical & Surgical History:
Vital Signs T:
P:
R:
B/P:
Clinical Details & Description of Present Case:
Cause: ☐Physical Illness ☐Accident ☐Maternity ☐Preventive...
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