New Patient Adult Forms - Fill this out for all patients 18 years old and over Additional Information for Dr Paz - Complete this if you will be seeing Dr Pazuchowski Additional Information for Angela Collinson - Complete this if you will be seeing Nurse Practitioner Collinson New Patient Pediatric Forms Release of Information to Spouse/Relative Records Release - To get your old records from another doctor 3- Day Diet Diary Medical Symptom Questionairre Blood Pressure Log - A simple chart to keep track of your blood pressure readings Basal Body Temperature

ST. John Center for Wellness and Family Medicine 18303 Ten Mile Road _______Suite 500 Roseville, Michigan 48066 Phone:586-498-5160 Fax: 586-498-5199

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For a Lifetime of Health

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