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Urology Specialists








Patient Name

Date of Birth
DateInitialLatex Allergy Yes______ No ______
When First
Recorded
ALLEGIES Reaction:






























PLEASE PROVIDE US WITH A CURRENT LIST OF ALL YOUR
MEDICATIONS (Including Over the Counter, Herbals and Vitamins)
AND ALLERGIES AND RETURN TO OUR OFFICE.
Date Medication
First Recorded
Office Use Only -- If medication discontinued or dosage changed
highlight with pink through the drug, enter the date and sign.
Med List and
Allergies Reviewed
DateInitial  MEDICATION                                  DOSE                                 HOW OFTEN DateInitital















































































































Signatures on file in Lab Manual