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Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Surgical History

* Required Information

Please mark all surgeries you have had.

Prostate Surgery
Gallbladder Surgery
Colon Polyp Removal
Colon Removal
Hysterectomy (due to cancer)
Hysterectomy (not due to cancer)
Dilation and Curettage (D&C)
Spinal Fusion
Spinal Decompression
Lung Surgery
Kidney Removal
Cataract Surgery
Breast Cancer Lump Removal
Breast Reconstruction
Breast Reduction
Ovary Removal
Carpal Tunnel Surgery
Rotator Cuff Repair
Arthroscopic Shoulder Surgery
Hip Fracture & Surgery
Total Hip Replacement
Total Knee Replacement
Arthroscopic Knee Surgery
Foot Surgery
Varicose Vein Procedure
Thyroid Removal
Breast Biopsy
Carotid Artery Surgery
Open Inguinal Hernia Surgery
Laparoscopic Inguinal Hernia Surgery
Caesarean Section
Heart Valve Replacement
Heart Bypass Surgery

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