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b

Patient’s Name: _____________________________________ DOB: _____________________


Contact Person: ________________________________ Contact #:
______________________
Indication for anticoagulation therapy:
Atrial fibrillation Deep Vein Thrombosis Mechanical valve
Cerebrovascular accident Pulmonary embolism Other: _________________________
Start date: _____/_____/_____ Therapy Duration: 3 months 6 months 1 year Indefinite Other: _______________

Next INR
Date Current Dose PT/INR Complications Initials New Dose Due MD Signature

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

None Noted/Reported
Lab Performed In-office

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