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Trea tmen t Give n/Pr oced ure Perf orm ed

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Con ditio n at the time of Disc harg e

Trea tme nt Advi sed


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Nex t Visit _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Con tact Hos pital in Case of Eme rgen cy

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Stam p ~Si ;~;t ~-r~ ·of Con sulta nt

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