Patient Information

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Title *
Gender *
Do you have medical insurance? *
Are you receiving any medical treatment at the present time? *
Have you ever been in hospital? *
Have you ever had? *
Are you taking any tablets, capsules, medicine or drugs? *
Have you had any allergies to medicines that you are aware of? *
Are you wearing an artificial or prosthetic joint? *
Have you ever experienced excessive bleeding or bruising from dental treatment, cut or scratches? *
Have you ever had contact with the AIDS or Hepatitis B virus? *
Have you ever had a reaction to an anaesthetic? *
(Woman) Are you pregnant? *