In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence.
if yes, complete the following:
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Excessive Exposure
Father
Mother
Siblings
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Spouse
Children
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Please list any illnesses or issues you have experienced in the last 1-2 months and indicated how often it occurs by following the guide below.
1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly
Eyes/Ears/Nose/Throat/Respiratory
Muscular/Skeletal
Neurological
General
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services Imay needs.
Before signing below, please read our Patient/Client's Rights and Responsibilities.
Before signing below, please read our Medical Consent to Treat.
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