WELCOME TO ADAMS DENTAL WOULD YOU PLEASE FILL OUT THIS FORM PERSONAL DETAILS (Dr Mr Mrs Miss Ms) Surname:______________________________________________________ Christian Names: _____________________________________________ D.O.B:________________ Private Address:____________________________________________________________________ Postal Address: ____________________________________________________________________ Occupation: _______________________________________________________________________ Home:____________________ Business:____________________ Mobile:_____________________ Email Address______________________________________________________________________ Who is responsible for this account? ___________________________________________________ Who can we thank for recommending you to this practice?_________________________________ Are you covered by private health cover?
If yes, which fund ___________________ Patient Number on your card next to your name 00 / 01 / 02 / 03 / 04 / 05 / 06 Reason for your visit today? (e.g. tooth ache, check up, clean, aesthetics) _________________________________________________________________________________
Are you interested in? TEETH WHITENING AMALGAM REMOVAL DENTAL IMPLANTS VENEERS
When did you last visit your dentist?___________________________________________________ MEDICAL INFORMATION Who is your medical practitioner? _____________________________________________________
Are you a smoker? (please circle) NO EX-SMOKER SOCIAL MODERATE HEAVY Are you taking ANY medication or supplements? (Including but not limited to contraceptive pill, vitamins, dietary supplement, asprin, warfarin, fosamax) _________________________________________________________________________________
Please list ANY allergies to food or medicines? (e.g. Antibiotics, Codeine, Milk Products) _________________________________________________________________________________
Ladies, do you think you may be pregnant? (please circle)
Do you have ANY medical conditions?
Please specify or add any relevant details: _________________________________________________________________________________ Signed:______________________________________________ Date:______________________
Thank you for providing this important information which will remain part of your personal and
C Ferrer Olmedo, et al. ONTRIBUCIÓN O Rivastigmina en pacientes con Parkinson y trastornos cognitivos enfermedad de Parkinson y trastornos cognitivos Experience with the use of rivastigmine in patients with Parkinson’s disease and cognitive disorders Ferrer Olmedo,*,† Soto María Cristina,* Ferrer Yenny,‡ Ferrer Arelis,‡Ferrer Yuseppi,¶ Hernández Armando,* Pachano Fr
Short report UDC: 616.98:725.51(497.113) Archive of Oncology 2000;8(3):185-6. Gorana ∆OSI∆1 Hospital-acquired infections at the Nataπa LUKI∆2 Marica MILADINOV-MIKOV2 Institute of Oncology Sremska Kamenica 1I1INSTITUTE OF PUBLIC HEALTH, DEPARTMENT OF Key words: Hospital infection; Epidemiologic studies; Oncology EPIDEMIOLOGY, NOVI SAD, YUGOSLAVIA2INSTITUTE OF ONCOLOG
WELCOME TO ADAMS DENTAL WOULD YOU PLEASE FILL OUT THIS FORM