Enfin disponible en Europe, grâce à une étonnante formule France, 100% naturelle, vous pouvez maintenant dire stop à vos problèmes d’impuissance et à vos troubles de la virilité. Cette formule révolutionnaire agit comme un véritable achat cialis naturel. Ses résultats sont immédiats, sans aucun effet secondaire et vos érections sont durables, quelque soit votre âge. Même si vous avez plus de 50 ans !

Southerndentalgroup.net

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. We are
looking forward to working with you on maintaining your health.

Patient Information
Patient_____________________________________________________Sex: M F DOB:___________________ Marital: S M W D Address____________________________________ _______City _______________ State ____________ Zip __________________ Home Phone _______________________Cell _____________________SS # ___________________Pharmacy _________________ Email ______________________________________Occupation/Employer _____________________Work Phone_______________ Who should be notified in case of an emergency?____________________________________ # ______________________________ How would you prefer for us to contact you? Home phone Work phone Cell phone Whom may we thank for referring you to our office? _________________________________________________________________ Primary Dental Insurance
Insured’s Name___________________________Relationship ________________ DOB ______________SS#___________________ Address_____________________________________________________________________________________________________ Employer _______________________________ _Insurance Co.________________________________________________________ Secondary Dental Insurance
Insured’s Name___________________________Relationship ________________ DOB _________ _SS#______________________ Address_____________________________________________________________________________________________________ Employer _______________________________ Insurance Co._________________________________________________________ Medical History
Former Dentist___________________________ Address_________________________________ Phone # _____________________
Physician’s Name___________________________________ Phone # ____________________ Last Visit ______________________
Are you currently under a physician’s care? ________ _If yes, describe __________________________________________________
Have you ever been hospitalized, had major operations or serious illness? ________________________________________________
Have you ever had a blood transfusion? _________ If yes, give approximate dates _________________________________________
Women: Do you suspect that you are pregnant? ______Are you nursing? _______ Do you take birth control pills?________________
Do you use any tobacco products? _______What kind? ________________ How long? ________How much per day?_____________
Please check if you currently have, or have ever had any of the following:
__ Mitral Valve Prolapse
Are you taking or have you ever taken bone replacement medications? (Ex. Boniva, Fosamax, Actonel, Zometa, etc.) _____________
____________________________________________________________________________________________________________
List any medications you are currently taking_______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List any drug allergies__________________________________________________________________________________________
- I authorize the release of my dental records and medical information to Dr. Michael E. Pope.
- I consent to treatment considered necessary by the dentist or qualified designate.
Signature______________________________________________________________ Date ________________________________

Source: http://www.southerndentalgroup.net/docs/patientwelcome.pdf

Pre-employ-health-survey_revised.cdr

1 0 1 5 E . S e m o r a n B l v d , S u i t e 2 0 9 w w w . m e d t e a m s t a ff i n g . c o m PRE-EMPLOYMENT HEALTH SURVEY This Health Survey is a MEDTEAM STAFFING PRE-EMPLOYMENT REQUIREMENT and is intended to be a work-related assessment of my ability to perform without limitation. I certify that the answers to all survey questions are true and understand that misrepresent

Recyclable heterogeneous catalyst for conversion of oils to biodiesel

IOWA STATE UNIVERSITY OF SCIENCE AND TECHNOLOGY Novel Protein Kinase D1 Peptide Modulators to Block Neurodegeneration APPLICATION AREAS Development of Drugs for Parkinson’s Disease; PKD1 Activators; Enhancement of Mitochondrial Function ABSTRACT Parkinson’s disease (PD) is a progressive, neurodegenerative disorder in which dopamine-producing cells in the substa

Copyright © 2010-2014 Online pdf catalog