FIRST VISIT PATIENT INFORMATION FORM

Basic Information
Medical Information

Please fill in carefully. It is very important for the TCM doctor to fully understand your current situation. 请务必认真填写。让医生全面了解你的现状，对治疗是非常重要的。

I understand by signing and submitting this form that the information provided is true to the best of my knowledge. I will advise this clinic of any changes to the above details during future visits.
Noted by HS Chinese Medicine Clinic. Copyright by HSCM

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