Physical Exam Form

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Your primary care doctor must fill out this exact form.
Please bring with you on your first visit.
Your physical exam needs to be less than 30 days old.
This form is for both pediatric & adult patients and is required for patients potentially undergoing surgery.
No other form will be accepted by our surgery center.
Should patients not have the physical form complete, it would delay any surgical procedure that may be required.

For a child, their pediatrician must complete the form prior to your initial visit.