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Or pregnancy. Last and first name of the insured person: Date of birth: D D MM Y Y Y Y Last and first name of the patient: Date of birth: D D MM Y Y Y Y Diagnosis: When did the first symptoms become apparent? Date: D D MM Y Y Y Y When did the first treatment take place? Date: D D MM Y Y Y Y Yes No Date: D D MM Y Y Y Y Was the patient unable to work? Yes No Duration: Was the patient capable of travelling at the time of booking? Yes No Was there an accide.

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