Are you now taking or have you taken
Please list any medications, including over the counter, you are currently taking and/ or attach a list:
Are you allergic to or had a reaction to
Is there a FAMILY HISTORY of
In case of emergency, contact:
Women Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/ gynecologist for assistance regarding additional methods of birth control.
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his staff, responsible for any errors or omissions that I have made in the completion of this form.
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