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Patient details
Please complete this form, print it off, and bring it to your first appointment
with Kerry. Your answers will not be saved on this website.
Name
Date of birth
Address
Telephone
Mobile
E-mail
Doctor's name
Doctor's address
Current medication
Recent operations
Medical conditions
Heart problems Diabetes Epilepsy
High blood pressure Low blood pressure
Viral infections I am pregnant
Consent
I consent to having acupuncture
© Kerry Marshall 2005, all rights reserved