new patient forms

DANISH MED SPA

REGISTRATION FORM

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THE FOLLOWING INFORMATION WILL HELP US TO SERVE YOU BETTER. YOUR RESPONSES ARE HELD STRICTLY CONFIDENTIAL.


PLEASE PRINT CLEARLY.

IF MINOR:

Please download the patient forms:

(Two options to submit patient forms)


1. Fill it out and bring it in during your visit

2. Fill it out online and submit electronically.

HEALTH HISTORY QUESTIONNAIRE

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I certify that the above information is true.

PLEASE CONTINUE.......

Myra N. Danish, md, facs

4550 investment Drive STE#290

Troy, MI 48098

248-267-9700

Acknowledgment of the notice of privacy practices

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I acknowledge that I have received the Notice of Privacy Practices


Please list name of person(s) that you would allow our office to give information to regarding your medical condition.

Please notify our office in writing with any changes to the above list.


Please see a member of our staff with any questions that you may have regarding our Notice of Privacy Practices.


Notice of Privacy/2023