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Medical History Form

MEDICAL HISTORY

What is your estimate of your general health?

Excellent Good Fair Poor

MEDICATION TREATMENT HISTORY

Describe any current medical treatment, impending surgery or other treatment that may possibly affect your dental treatment.

List all medications, supplements and/or vitamins taken within last two years

PLEASE ADVISE US OF ANY CHANGE IN YOUR MEDICATIONS OR MEDICAL HISTORY

PATIENT SIGNATURE

Signature of Patient/Legal Guardian:

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Date:-------------

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