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MEDICAL / DENTAL HISTORY

Please SELECT any of the following which you have or have had in the past


MEDICAL / DENTAL HISTORY

Please list all physicians and their specialty:

Please list any current medications you are taking and reason. Include prescriptions, supplements, and over the counter.

Have you experienced an allergic or unusual reaction to any of the following?

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during my diagnosis and treatment with my informed consent.