Do you have, or have you had, any of the following?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing Incorrect Information car be dangerous to my (or patients) 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.