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Month/Day/Complete Year

PRESCRIPTION MEDICATIONS -- List all medications you are presently taking.

NON-PRESCRIPTION MEDICATIONS -- List all non-prescription medications you are presently taking. Include over-the-counter medications, vitamins/supplements, herbals, and creams.


ALLERGIES -- List all allergies or unusual reactions you have to medications, foods, dyes, latex, and other agents.

ADULT IMMUNIZATIONS -- Check the box next to or list all immunizations received including the most recent date received.


10806 Reisterstown Rd, Ste 1F 
Owings Mills, MD 21117

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We operate by Appointments Only

Open Hours

Tuesday – Friday: 8:30am – 6pm
Monday & Saturday: 10am – 4pm

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