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Medical History Form

To complete this Medical History Form, simply fill out the fields with the requested information. While most of the fields are optional, certain fields marked by asterisks (*) must be completed. Please do not use your browser's Back or Forward buttons. Use of these buttons may “undo”/”redo” recent actions. Once you have completed this document, simply click the submit button to proceed.

Name
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above?
Are you under a physician's care now?
Have you ever been hospitalized/had a major surgery?
Have you ever had a serious head or neck injury?
Do you have any Medical Concerns?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco products?
Are you allergic to any of the following?
Do you take any medications or Supplements?
Women: Are you...

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing 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.

Please draw your signature in the box. Use the X to clear your signature.

Please carefully review your information before submitting this document.