📄 Extracted Text (140 words)
Department of Plastic Surgery
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MEDICAL CENTER
Patient Pre-Visit Worksheet
Legal Nam*: -reccas9 EPS -re /4 MRNpras•uewa
Date of Birth I -C3 Age: CA —
Reason for Visit:
Medical Wilsey: 0 None
Do you have a history of fainting or seizures? NO OYES
Surgical History - Please list dates, if any: cp None
Allergies - Please list Reactions: 0 None 0 Latex:
0 CBncr:
Social History:
Highest Level of Education:
Occupation:
Marital Status (*thy. one) estnglr O>Aarried OD.Norced OWidowed 0 Partnered
Tobacco Use
Alcohol Use:
Illicit Drug Use
Family Medical History.
Current Medication with Usage:
Is it okay to leave you a voicemail with possible confidential
information:ONO 0 YES, PREFI
Patient Signature.
Date q I I?
Name of Person completing this form n.;. tht1•4144,1':
Relationship to Patient:
Signature.
Date -
EFTA00313910
ℹ️ Document Details
SHA-256
175476e830d59f5cb816d45680ec9dd87b5b2273fda8a18279b416c8d4d8223b
Bates Number
EFTA00313910
Dataset
DataSet-9
Document Type
document
Pages
1
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