Patient Information:
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Emergency Contact:
Insurance Information:
Medical History:
Do you have any allergies?
- Anaphylactic Allergy
- Aspirin
- Bactrim
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- Ibuprofen
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- seasonal
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Do you have any of the following conditions?
- Abnormal/excessive bleeding
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- Angina Chest
- Any Implant/transplant
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- Prolapsed Mitral Valve
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Do you experience any of the following?
- Gum Bleeding
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