Patient Information

    malefemale

    MarriedSingleChildOther





    Health Information

    Have you ever had any of the following? Please check those that apply:

    AIDSAllergiesAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersNervous DisordersPacemakerPregnancyRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseCodeine AllergyPenicillin Allergy

    Have you ever had any complications following dental treatment?
    YesNo






    To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

    Referral Information

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