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Patient First-Visit Health Information

I use this to contact you for any follow-up questions I may have. I will not share this information with any other people.
Your mobile number is preferred to make contacting you easier.
Describe the problem(s) you have that you'd like treatment for.
Please provide the name and doses of all medication and for what condition(s).
If you have no allergies or drug sensitivities, please type no.
Optional. For example, do any diseases run in your family - for example diabetes or heart disease?
By digitally signing your name here, you are indicating consent for me to use the information provided above to inform how I should treat you. Please rest assured, your information is not used for anything else.