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Information & Medical History

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EMERGENCY CONTACT

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Medical History

The Following information is required to enable us to provide you with the best possible dental care. All information is trictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Date

Describe any current medical treatment, impending surgery, genetic/development delay, or any other treatment that may possibly affect your dental treatment. (ie. Botox, Collagen injections, etc)

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List all medications, supplements, vitamins and/or probiotics taken within the last two years.

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PLEASE ADVISE US IN THE FUTURE OF ANY CHANGES IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING

(e.g. rheumatoid arthritis, lupus, scleroderma)
(e.g. Alzheimer’s disease, dementia, prion disease)

ARE YOU:

(e.g., fever, chills, new cough, or diarrhea)
(e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)
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