A thorough medical history is an important part of your record. Please answer all questions accurately because it will allow us to provide you the best possible treatment from a fully informed health professional. If you don’t know, or do not understand the question please leave blank.
This information will only be used to determine financial eligibility and/or provide medical or dental treatment at the Clinic.
I certify that the information above is accurate to the best of my knowledge.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.