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And sign the form. At later visits we will check the information given to see if there have been any changes in your general health. All information will be kept strictly confidential. TITLE: NAME: D.O.B.: ADDRESS: TEL.NO. HOME: WORK; Email address; OCCUPATION: Please sign here if you agree to us telephoning and leaving a message at this number . DOCTOR S NAME & ADDRESS ARE YOU: YES NO DETAILS 1. Pregnant 2. Attending or receiving treatment from a d.

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