Health History Form

Please correct the errors described below.

A. Dental History

B. Medical History

Women Only:

Are you allergic to or have you had reactions to:

Do you have or have you ever had the following:

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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

MEDICAL HISTORY UPDATE:

INITIALS

Add History

Your information will be encrypted.

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