Medical/Health History Form

Brown & Gettings, DDS

Please correct the errors described below.

Patient Information

Emergency Contact Information

Add emergency contact

Medical History

DO YOU HAVE or HAVE YOU EVER HAD:

An allergic or bad reaction to any of the following:

ARE YOU:

List all medications, supplements, and or vitamins taken within the last two years:

Add Medication/Supplement/Vitamin

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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