Email address: * |
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Home phone: * |
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Driver’s license#: |
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Employer: |
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How did you hear about us?
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Other family members seen by us:
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Do you have a medical condition that requires you to take antibiotics before dental treatment?
such as : Jiont Replacement Surgeries, Heart Valve Replacements, Organ Transplant... If So Please Explain :
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Please Explain : (list the medication you are currently taking)
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Please list any serious medical condition(s) that you have ever had:
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Please list any other drugs / Materials that you are allergic to:
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Why have you come to the dentist today?
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If not, what would you change?
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