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PHYSICIAN SIGNING HOME CARE ORDERS PHYSICIAN NAME 2. 3. PMH: ALLERGIES: IS THE PATIENT HOMEBOUND? I YES I NO MEDICATIONS / DOSE / FREQUENCY / ROUTE: I Meds list attached CITY STATE TELEPHONE # ZIP FAX # ) ( NPI # ) LICENSE # DIABETES: OFFICE CONTACT TELEPHONE # I TYPE 2 I GESTATIONAL I Contact MD if blood glucose is above or below DATE I Current HbA1c Current gluclose OF I Glucometer and supplies.

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