PRIMARY INSURED
SECONDARY INSURED
For Office Use Only
Your mouth is a integral part of your body. Health problems you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will receive.
Thank you for answering the following questions.
To the best of my knowledge, the questions on this form have been accurately answered. I understand 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.
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