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Dr. Wasim Haque
V. Jane Zepeda, PA-C
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Forms For Appointment
To help us provide better care, we request that you print and fill out the following forms and bring them with you at your appointment:

1.  Patient Information Form   >     Download Word Version  |  Download PDF Version 

2.  Insurance Information Form   >     Download Word Version  |  Download PDF Version 

3.  Medical History Questionnaire   >     Download Word Version  |  Download PDF Version 

4.  Diabetes 1st Visit Questionnaire   >     Download Word Version  |  Download PDF Version 

If you are returning for follow up appointment regarding your diabetes management, please complete the "Diabetes Follow-up Questionnaire" and bring your glucometer with you. Please bring blood glucose records and your glucometer as well.

4.  Diabetes Follow-up Questionnaire   >     Download Word Version  |  Download PDF Version