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Individual Details

Referred by

Medical History

Do you have any of the following?

Diabetes

Yes No 

Epilepsy

Yes No 

Heart Disease

Yes No 

Liver Disease

Yes No 

Gout

Yes No 

Kidney Disease

Yes No 

High Blood Pressure

Yes No 

Asthma

Yes No 

Rheumatic Disease

Yes No 

Arthritis

Yes No 

Are you alergic to any of the following?

Local Anaesthetic:

Yes No 

Iodine:

Yes No 

Penicillan:

Yes No 

Plaster:

Yes No 

Other:

Yes No