CITY LOCALS APPLICATION - SECTION 3


MEDICAL INFORMATION

(IDD/LD-NOS is acceptable for unspecified diagnoses)
Current Primary Care Physician (if you do not have one, leave blank)
Current Primary Care Physician (if you do not have one, leave blank)
Phone number of current primary care physician (if you do not have one, just leave blank)
Phone number of current primary care physician (if you do not have one, just leave blank)
Please include name, specialty, and phone number for each
Date of Last Eye Exam
Date of Last Eye Exam
I wear the following to correct my vision:
Date of Last Dental Visit
Date of Last Dental Visit
I wear one of the following
Please include name of medication and dosage of each
Currently, with regard to my mental health: