(Please complete one form per body part)

NEW PATIENT Reorder #39866 PP0518 Page 2 of 2 Piedmont Graphics Rev. 10/31/18 None Past Medical History High blood pressure Kidney disease Kidney stones Diabetes If yes, do you use insulin? _____ HIV or AIDS Hepatitis Type _____ Thyroid problems Tuberculosis Tick bite MRSA history ................
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