Transcription of ANNUAL PATIENT INFORMATION UPDATES
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ANNUAL PATIENT INFORMATION UPDATES
ANNUAL PATIENT I NFORMATIO N UPDATES Pat ie nt Name: DOB: Today s Dat e: Email:Pref er red Phar mac y: Pharmac y Locatio n:Pharmac y Tel ephone:For Office Use Only: Portal Invite Sent ADVANCE CARE DIRECTIVES Do you hav e a liv ing will? Yes No Do you hav e a healthcar e power of attorney? Yes No Do you hav e a DNR (Do Not Resuscit at e) or der ? Yes No If you answered Y es to any of th e abov e questions, pl ease provid e our of fice wit h a copy for your records IMMUNIZ ATIONS Hav e you received a Pneumonia Vac cine? Yes Dat e_____ No Hav e you received an Influenza Vac cine?
Do y ou h av e a living wil l? Yes No Do you have a healthcare power of attorney? Yes No Do you have a DNR (Do Not Resuscitate) order? Yes No If you answered “Yes” to any of the above questions, please provide our office with a copy for your records IMMUNIZATIONS H av …
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