I need a simple template with header (blue ridge physician associates) and what amounts to a patient intake form with basic information boxes (name, address, city/state, zip, phone boxes) and emergency contact information (fill in blank with name/relationship/phone number boxes), reason for visit (fill in blank), patient history (fill in blank versus checkboxes), precriptions (fill in the blank), allergies (fill in blank), family medical history (fill in blank), prior surgeries or hospitalization (fill in

I need a simple template with header (Blue Ridge Physician Associates) and what amounts to a patient intake form with basic information boxes (name, address, city/state, zip, phone boxes) and emergency contact information (fill in blank with name/relationship/phone number boxes), reason for visit (fill in blank), patient history (fill in blank versus checkboxes), precriptions (fill in the blank), allergies (fill in blank), family medical history (fill in blank), prior surgeries or hospitalization (fill in blank).

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