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Download medical referral form template. The patient medical history form template is used by patients to register clinical history through providing their personal and contact information, weight, drug allergies, illnesses, operations, healthy habits, unhealthy habits. Form fda 3926 (7/22) page 1 of 3. Doctors and healthcare providers alike can use this medical referral form to refer patients to receive additional health care services. See pra statement on last page.
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