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Crystal Salt

Consent Form

 Please check any condition you have or have had.

Conditions

Past Surgical History Please list any surgeries that you have had

Surgery

Date

Social History Please check all that apply

Family Medical History

Disease

Family Member

Has anyone in your family had thyroid cancer?
Has anyone in your family had multiple endocrine neoplasia

Current Medications

Medication Name

Dose/Frequency

Medication Allergies

Drug Name

Reaction

I attest the above information is true and accurate to the best of my knowledge.

Thanks for submitting!

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