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MEDICAL HISTORY

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

Continued Medical History

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

Please list all physicians and their specialty:

List ALL medications you are taking and reason. Include prescription, supplements, and over the counter. (Include any blood thinning herbal medications or supplements such as: Vitamin E, garlic, fish oil, any oils, bilberry bromelain, cat's claw, devil's claw, dong quai, evening primrose, feverfew, ginger (at high doses), ginkgo biloba, grape seed, ginseng, green tea, horse chestnut, and turmeric.)

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 of 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 diagnosis and treatment with my informed consent.

Dental History

Special Considerations

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