Medical Form

Do you take?

Has there any problem with your health in the last 5 years?
YesNo

If yes, please explain

Have you ever been advised to take antibiotics prior to a dental appointment?
YesNo

Are you presently under any physicians care?
YesNo

If yes, please explain

Name of Physician:

Phone # or City

Are you presently taking any medications? (Please List)

Do you smoke?
YesNo

Have you ever had any complications following dental treatment?
YesNo

Do you have any health issues or problems that need further clarification, or anything else that you think the doctor should know about?
YesNo

To the best of my knowledge, this information is complete and correct. If I ever have a change in my health, I will inform the doctors at the next dental appointment.

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