Patients

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Medical History Form

Personal Information

Name

Age

Gender

Street Address

City/State

Zip Code

Phone Number

Email Address

Please email me updates

Height

Weight: (lb)

Waist:(in)

BMI

Medical Information

Procedure(s) requested?

When (month/date) are you interested in getting the procedures completed?

Please write a short description of why you are interested in traveling
internationally to get your medical procedures completed.

	Excellent	Good	Fair	Poor
How would you rate your general health?

REVIEW OF SYMPTOMS: Please check any CURRENT symptoms you have.

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