Medical History Update

Dentistry at South Brunswick

Please correct the errors described below.

MEDICAL/DENTAL HISTORY - Have you ever had any of the following? (Check the boxes that apply)

Please list medications/doses you are currently taking:

Add Medication

Women

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form:

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.

Your information will be encrypted.

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