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PHYSICIAN INFORMATION
HEALTH HISTORY
Do you have or have you had (if yes, give date of occurence)
DAILY HABITS
BLEEDING
MEDICATIONS
Medications (prescription and non-prescription) that you have taken within the last month if not noted above:
FAMILY HISTORY
Do you know of any blood relative who has or had (check and give relationship)
SURGERY HISTORY
WOMEN ONLY
Note: We recommend regular breast and pelvic exams by your regular physician or gynecologist
MEN ONLY
The above information is true to the best of my knoweldge.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.