Patient Medical History Form

Amazing Smile Family Dental Center

Please correct the errors described below.

Dental Sleep Solution of NH

To the best of my knowledge, the questions on this form have been accurate 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.

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

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