MEDICAL UPDATE FORM


Health History


For Women Only


Have you had or do you currently have the following:

Social History


Medications


Allergies/ Reactions



Form Completion

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

If Patient is a Minor

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