Current Medications

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    Name [first-name] [last-name]
    aka: [preferred-name]
    Address [address-line-1] [address-line-2]
    City/State/Zip [city] [state] [zip-code]
    Home Phone [home-phone]
    Birthdate/Age [birthdate] / [age]
    Cell Phone [cell-phone]
    Status [status]
    Gender [gender]
    SSN [ssn]
    Employer [employer]
    Work Phone [work-phone]
    How Did You Hear About Us [how-hear]
    Dental Insurance [dental-insurance]
    Secondary Dental Insurance [secondary-dental-insurance]
    These were the Medications: [meds] Meds #[group_index]Medication: [medication]Reason: [reason]Doctor: [doctor] [/meds]
    Agreement 4 [agreement-4]
    Agreement 5 [agreement-5]
    Responsible Party Name [responsible-party-name]
    Relationship to Patient [relationship-to-patient]
    Date of Agreement [date-agreement]
    Health History [health-history]
    Explaination [explain]
    Primary Physician [primary-physician]
    Physician Phone [physician-phone]
    Pre-Medicated [pre-medicated]
    Pregnant? [pregnant] Due Date: [due-date]
    Nursing [nursing]
    Current Medications [current-medications]
    Allergies [allergies]
    Other Allergies [other-allergies]
    Patient Name [patient-name]
    Guardian Name [guardian-name]
    Date Signed [_date]
    Your Message [your-message]

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