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Obesity Related Problems
If yes, briefly explain:
Gastro Esophageal Reflux
Digestive System Problems
Do you smoke?
If you answered yes, are you in treatment and what is your treatment?:
What kind of diets have your carried out? (how long?):
Any allergies that the doctor should know about? (please list):
Currently taking Medications? (please list):
Have you had previous abdominal surgeries? (If yes, explain):
Not listed on how you heard about us? type in here:
Do you have a friend or family member that would like to refer to us? Receive $100 per patient referral:
If you answered yes, please write down your referrals names and cell phone numbers:
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"On the road to a better you"
- Let us help youDedicated Patient Coordinator Team