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STRICTLY CONFIDENTIAL / Data protection:
The Elixir Clinic will use the information you give to help with assessment of your health. Your information will not be disclosed to anyone else without your agreement.
PAST MEDICAL HISTORY
Do you have now, or have you ever had any of the diseases/conditions listed bellow?
I understand that I must inform the Doctor or Clinic if there are any changesto my personal or medical details between treatments. I agree that I have answered the above questions honestly and to the best of my knowledge.