INFORMATION SHEET

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Name
Address
I was referred by :
Service(s)
YEAR-MONTH-DAY
Do you suffer from heart disease?
Do you suffer from diabetes ?
Do you suffer from hepatitis?
Do you suffer from HIV?
Do you take medication?
Do you freeze easily at the dentist?
Do you have any physical disabilities?
Do you suffer from allergies?
Do you have any permanent makeup or tattoos?
YOUR EYES:
Have you had an eye operation?
Do you suffer from glaucoma?
Herpes (cold sores)?
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to the best of my knowledge
Clear Signature
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