New Patient Forms

Patient Medical Information Form

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AllergiesJewelry allergyNickel allergyTuberculosisKidney disordersLiver disordersBleeding disordersRheumatic feverHeart murmurHeart diseaseHeart surgeryDiabetesRespiratory problemsAsthmaGlaucomaEpilepsyVenereal diseaseGonorrheaFrequent headachesEarachesHigh/low blood pressureFacial muscle painCancer-any typeRadiation treatmentProsthetic treatmentNervous disorderHIV+