Online Patient Form - Part 2/3

Please fill in the form below

Patient Medical History

Are you allergic to or have you had any reactions to the following?

Have you ever had any of the following?

Please select those that apply


Patient Dental History

Are you experiencing any of the following problems in your jaw:

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis & the records of any treatment or examination rendered to me or child during the period of such dental care to third party payers and or health practitioners.
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