Patient Data

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Serve
Name
DOBymd   Mr   Mrs   Ms   Miss
Occupation
Home St.
   City   St/Prov
   Country   Zip/Postal
Tel. Home   Work　Cell
   Other
Fax.
E-mail(Essential)
Problem   Durationymd

Present:

Note:

On-line Tang Fang and takes the side in the distribution center not to have to fill in this table, exclusive Tang Fang and Chinese medicine faculty then essential fill in this table (at the same time first to pay doctor's fee);
This form may voluntarily photocopy the use, also may manually transcribe (capital letter regular script to be neat);
If has recommendation, under the same situation can attain first processes (for example in information bank to have correlation recording);
In this website does not suppose the information bank, thinks the security.