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- Preferred pronoun
- Gender identity for medical purpose
- Birthday*
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- How soon are you looking to have the treatment?*
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- Which location do you prefer?
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- Which financing options do you prefer?*
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- Have you ever been diagnosed with any form of cancer?
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- Has any member of your family had any of the following illnesses?
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- When was your last medical check up?
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- Check the symptoms that you' re currently experiencing:*
- Are you currently taking any medication?*
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- Do you have any allergies and adverse drug reactions?*
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- Do you currently smoke or chew tobacco?
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- Do you currently drink alchohol, beer or wine?
- If yes, how often you drink
- Do you have dental X-rays taken in the past 6 months?
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- Should be Empty: