Are you allergic to, or had a reaction to any of the following:
WARNING: Antibiotics (such as penicillin) may alter the effectiveness
of birth control pills. Consult your physician for assistance regarding
additional methods of birth control.
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