Hsu Huang Patient Registration Page 2

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MEDICATION FORM
FOR THE OFFICE OF C.E. HUANG AND C.S. HSU, M.D.
NAME:
Date of Birth:
ALLERGIC TO:
REACTION:
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING:
OVER
COUNTER
,
Prescriptions and
the
medications (examples: aspirin, antacids); Herbals (ginseng
gingko, and Echinacea); and, include medications taken as needed (pain pills, nitroglycerin tablets).
Today's
Drug Name &
Dose of
Medication:
Date
Strength
You may obtain additonal copy of this form at any time by asking at the reception desk.

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