Do we have permission to contact you electronically?
Details of person to contact in an emergency:
8) Have you ever had or currently have any of the following? If so, please tick as appropriate:
I confirm that I have read and understood this medical form. I confirm to the best of my knowledge; this is a true and accurate description of my medical history and current conditions.
I understand that withholding any information may be detrimental to my health during the procedure. If there is any change in my medical history, it is my responsibility to inform my practitioner.
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