| Document Date: 2012-01-28 03:10:34
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City Seattle / / Company Thomas L. Vo D.D. / / Currency USD / / IndustryTerm dental services / insurance / cancer treatment / rubber / insurance claim / food / / MedicalCondition severe headaches / Surgery____ Radiation____ Chemotherapy____ ___Heart Problem ___Heart Murmur ___Heart Valve problem ___Pacemaker ___Artificial Heart Valve ___Blood pressure problem ___Anemia ___Easy Bruising ___Abnormal Bleeding/Blood Disease ___Seasonal Allergies / jaw pain / cancer / disease / ___High blood pressure / Stroke / cold sores / ___Oral Herpes / neurological disease / borne disease / chemical dependency ___Fainting / respiratory disease ___Hepatitis / osteoporosis / aphthous ulcers / canker sores / Dry mouth ___Tuberculosis / ___Ulcers ___Arthritis ___Frequent Heartburn/GERD ___Diabetes / Seizures ___Epilepsy / Asthma / / MedicalTreatment premedication / Joint Replacement / antibiotics / Natural remedies / Chemotherapy / Surgery / Radiation / / Organization U.S. Securities and Exchange Commission / / Position treating dentist / physician / / Product Fosamax / Orinase / Acetaminophen / Coumadin / Penicillin / Ibuprofen / Aredia / Medication / Technology Radiation / cellular telephone / Chemotherapy / /
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MEDICAL ALERT ________________________ PATIENT REGISTRATION (Please Print) PATIENT__________________________________________________________________________________________________________________________________________