PRE-CONSULTATION QUESTIONNAIRE

This questionnaire is to provide Dr Floreani with your medical information. If you are seeing Dr Floreani for concerns with the function and/or appearance of your nose, this information helps Dr Floreani understand your concerns and enables him to provide a tailored approach to your care. Please be as detailed as possible with your answers.

General Information

Health Information

Please list any medications you are currently taking

Please list any allergies

Consent

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