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Available Forms

Alignment Care Center Appointment Request Alignment Referral Form Back Pain E-Visit Blood Pressure Log Blood Sugar Readings Cold/Sinus/Cough/Throat/Respitory Infaction E-Visit Conjunctivitis/Pink Eye E-Visit Depression Screening (PHQ9) Health Care Question Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam Prescription Refill Request Referral Question Specialist/Urgent Care or Hospital Visits Survey Triangle Medical Group Urinary Tract Infection E-Visit Yeast Infection E-Visit

Blood Sugar Readings

Name *

Date of Birth *

Approximate date of last visit *

Choose your provider *

Are you taking medicines for lowering blood sugar?

Yes

No

Are you taking Insulin?

Yes

No

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Blood Sugar Readings

Enter Date Time and Blood Sugar

Add any Comments

Chose your Medical Practice

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