Patient History

Brit Phillips, DDS, PA

Please correct the errors described below.

Primary Insurance Information

Secondary Insurance Information

Medical History Information


Do you have, or have you ever had, any of the following?Please answer All questions.

Medications

Current medications. (Including prescription, over-the-counter, supplements, vitamins and herbs) If you are currently not taking any medications, supplements, or any natural products, please write NO MEDICATIONS on the first line and sign the bottom.

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