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Submission Time | First Name | Last Name | Email | Cell Phone Number | Birthday | Physical / Business Address: | First time registering? | Relevant sessions | Do you have any Known allergies? If Yes Please List | Next of Kin Name & Contact Number | Please list your known medical conditions & Treatment | Please list your current symptoms | Medical Aid & Plan | Email 2 | I agree to the terms & conditions of the Practice | Enter medical aid number | Photo for your Personal Medical File | Dependant code E.g (00) (01) | Covid-19 Rapid Test Result | Temprature, Pulse, Blood Presssure | Title | Weight | Height | Gender | New Field-1 |
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