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DENTAL & MEDICAL HISTORY :

Please tick the box and input details, if any of the following applies. When you are not sure about the answer, please tick the box and type "unsure" or specify your concerns.

Have you had or do you have any of the following?

MEDICAL CONDITIONS:


SERVICE IMPROVEMENTS:

PATIENT DECLARATION:

I declare that I have completed this form to the best of my knowledge, and that the information provided is an accurate medical history of the above mentioned patient. On future visits, I will advise the dentist of any changes to the history.

(please click the box below to sign your signature)