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Medical History

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First Name*
Last Name
Are you currently being treated by a physician for a specific condition?

Have you recently been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Are you on a special diet?

Do you use tobacco?

Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.
Have you ever been advised that you require antibiotics prior to a dental appointment?

Do you take, or have you taken, PhenFen or Redux?

Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?

Have you recently used controlled substances?

Have you recently consumed alcohol?

Please answer if filling this form out on the day of your appointment

Women (Please check all that apply)
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *

Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

To the best of my knowledge, the questions on this form have been accurately answered.  I understand that providing incorrect information can be dangerous to my (or patient’s) health.  It is my responsibility to inform the dental office of any changes in medical status.

This field is for validation purposes and should be left unchanged.

Request Form

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