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Patient intake form
Patient information
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If someone else is responsible for the account
Medical aid details
Emergency & referral
Medical History
(Tick all that apply)
Untitled checkboxes field
Diabetes
Hypertension
HIV/AIDS
Arthritis
Asthma
Epilepsy
Cancer
Depression
Thyroid
Heart condition
Other
Relevant details or other conditions
Medication / Surgery (Last 5 Years)
Declaration
I confirm that the information above is accurate. I accept responsibility for payment and consent to
treatment.
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Signature
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