Patient Information (For Follow-up Visits)Updated Patient Information GENERAL INFORMATION Name * First Name Last Name Mobile Number * Country (###) ### #### Email MEDICAL INFORMATION What would you like to discuss with the doctor: * Any food or medication ALLERGIES? What kind of allergic reaction? Current medications (prescription medications, over-the-counter drugs, herbal remedies, vitamins & supplements), include dose and frequency: * Do you take any blood thinning medications (ex. Clopidogrel, Aspirin, Apixaban, etc)? * Do you use injectable medications (ex. Insulin, Ozempic, Prolia)? * INSURANCE INFORMATION Medical Insurance Coverage: (ex. Healthcare, PhilHealth, Company reimbursement, Senior/PWD, Self-Pay) Thank you !