• Medical-Dental History

  •  - -Pick a Date
  • 1.    Are you currently under the care of a physician for an existing condition?

  • 2.    Are you taking any prescription or over-the-counter medications?

  • 3.    Do you have any allergies?

  • 4.    Have you been hospitalized within the past year for any reason?

  • 5.    Do you have or have you had any of the following conditions?

  • 6.      Has antibiotic pre-medication ever been required for dental treatment?

  • 7.      Have you ever had any injuries to the face, mouth or teeth?

  • 8.      Have you been informed of any missing or extra permanent teeth?

  • 9.      Do any of the following conditions exist?

  • Thank you for completing this form. It will enable us to care for you in a more effective manner.

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