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  • Patient Information

    Patient Information
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  • Reason For Inquiry

  • We will need a total of 3 photos - from the front, left side, and right side are needed for the areas of concern.

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  • Medical History

  • Anything we need to know before the consultation? Asthma, bronchitis, lung problems? Heart disease, angina, arrhythmias, previous heart attack? Please provide information below:

  • Referral Source: How Did You Learn About Our Practice?

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  • Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Brucker Plastic Surgery, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

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