Physicians Script

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(xxx) xxx-xxxx
Split-night studies will be performed if criteria are met.
If the above symptoms don't describe the issue, please describe the symptom here.
Please list any medications the patient is currently taking. List each medication on it's own row. Enter "None" if patient takes no medication.
Please list any known allergies, each on it's own line. Enter "None" if no known allergies exist.
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