76 Boniface Dr. Ste 1, Pine Bush, NY 12566

Tel: 845-545-6212

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WeCARE

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Welcome To WeCARE Medical Office

PATIENT INFORMATION:

Today's Date

First Name

Last Name

Email

Street Address

Middle Name

Date of Birth

Sex

Phone

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Zip Code

EMERGENCY CONTACT INFORMATION:

Name

Street Address

State

Zip Code

Relationship

City

Phone

Email

INSURANCE INFORMATION:

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DR ERICKA M VALENZUELA MEDICAL OFFICE, PLLC