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Beauty in Prague Medical history form/Questionnaire Full Name : Sex: : female / male Address : E-mail Address: Telephone Number : Mobile Number : Note: Mobile numbers may be given to the clinic so that they may contact you once you arrive in Prague. Date of Birth : Are you being treated or have your been treated for any of the following? If yes, past or present, please click appropriate boxes and list medications prescribed: Allergies: Yes No Anaemia: Yes No Asthma: Yes No Birth control - The pill: Yes No......
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