• HEALTH HISTORY

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  • For the following questions select yes or no. Your answers are for our records only and are confidential. Please note that during your initial visit you will be asked some questions about your responses. Our team may ask additional questions concerning your health.
  • Women:
  • Are you allergic or have you had a reaction to:
  • Diet:
  • Doctor's Use only
  • I understand that above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, I will notify the doctor of change in my health and medication.
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