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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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Can we leave message on your home phone #
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Can we leave message on your Work Phone #
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Can we leave message on your Cell Phone #:
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Which number do you prefer us to call first
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With whom may we leave a message: Name
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Relationship
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Phone number
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Can we leave message with anyone
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Mail information to me in a (an)
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Mailing Address:
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If EMAIL COMMUNICATION, email address
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Like to receive email about discounts/newsletter
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Receive text and email communication from us?
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If yes, please do not forget to sign the email
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and text consent on the last page!
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Medical History
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Do you have any current/chronic illnesses?
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object to our office contacting your family
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Do you take aspirin product/headache medications
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Had any reaction to local/general anaesthesia?
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Do you smoke?
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If yes, How much?
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Do you Drink?
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If yes, How much
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Do you take blood thinners?
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Personal/family history of blood clotting?
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Do you take any supplements containing Vitamin E
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Do you or have you had a cardiac illness/inciden
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PLEASE LIST ALL PREVIOUS SURGERIES AND DATES:
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Family Doctor:
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Dr’s Phone:
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Name of the pharmacy
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Pharmacy's contact number
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