Book an Appoinment
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  • Name and Last Name*
    1
  • Date*
    2
  • Address*
    3
  • Phone*
    4
  • Email*
    5
  • Sex*
    Male
    Female
    6
  • Height*
    7
  • Age*
    8
  • Marital Status*
    Single
    Married
    Divorced
    Separated
    Widow
    9
  • Group
    10
  • Name of Spouse*
    11
  • Military Service*
    12
  • Children*to order
    Yes
    No
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  • Parent Living*
    Yes
    No
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  • Other Family Information*
    15
  • Education
    16
  • Last School Attended*full name
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  • State*
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  • Grade Completed*
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  • Collage Year Completed*
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  • Medical History
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  • Disses*
    22
  • Allergies*full name
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  • Surgeries*full name
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  • Medications*full name
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  • Habits*full name
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  • Alcohol*
    Yes
    No
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  • Tobacco*you like
    Yes
    No
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  • Coffee*you like
    Yes
    No
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  • Tea*you like
    Yes
    No
    30
  • Family History
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  • Special Diet*full name
    32
  • Family History*something more
    33
  • Family Physician*full name
    34
  • Last Visit*full name
    35
  • Are you in general good health*you like
    Yes
    No
    36
  • Are you presently in any physical discomfort?*you like
    Yes
    No
    37
  • If you have or have had any of the following, please check:*you like
    Cramps or Numbness
    Eye Trouble
    Diabetes
    Ear Trouble
    Kidney Trouble
    Heart Trouble
    Rheumatic Fever
    Tuberculosis
    High Blood Pressure
    Liver Trouble
    Asthma
    Blood Disease
    38
  • Comments*
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  • Paypal Transaction Id*input Correctly
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  • Captcha
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  • Group
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  • Name*full name
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