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119 Professional Center

1265 Wayne Avenue

Indiana, PA 15701

(724) 349-4411

fax (724) 349-5252

Klain, Heasley & Nettleton, MD

Internal Medicine Specialists

IRMC at Chestnut Ridge

25 Colony Boulevard

Blairsville, PA 15717

(724) 459-9111

fax (724) 459-7856

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Patient Info & Forms

First Time Patients

To speed up the check-in process, please complete and print all parts of this form prior to your appointment and bring it with you.

New Patient Forms

Returning Patients

To speed up the check-in process, please complete and print any requested form(s) prior to your appointment and bring them with you.

Patient Registration Form

Financial Agreement

Telephone Protocol Form

Records Release Form

Adult Medical History

Patient Consent Form

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