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Medical History Information

Have you ever had any serious illness is not listed above? 

 

 
 

Let’s all medications and supplements you were taking? 

To the best of my knowledge, the questions on this form has been accurately answered. I understand that they provide an incorrect information can be dangerous to my or patient’s health. It is my responsibility to inform the dental office of any changes in medical status. 

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Signature of patients or guardian  

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