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Medical History Update
adentaloffice.com
Medical History Update - A Dental Office
Date
Patient Name & Contact Information
Patient Name (First)
Patient Name (Middle)
Patient Name (Last)
Address
Address Line 1
City
Province
Postal Code
Home Phone
Work Phone
Cell Phone
Work Phone Extension
Email
Date of Birth
Gender
- Select -
Male
Female
Other
Family Status
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Single
Married
Separated
Divorced
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Medical History Update
Are there any changes to your Health History?
Yes
No
Please Provide More Information:
Are you being treated for any medical condition at present or within 2 years?
Yes
No
Please Provide More Information:
Have you been hospitalized in last 2 years?
Yes
No
Please Provide More Information:
List all medications currently being taken and reason for use : (including herbal and over the counter vitamins and supplements)
Allergies?
Yes
No
Please Provide More Information:
Signature of patient, parent or guardian (Print your name*)
Date
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705-726-3567
Or fill the form below.
Name
*
Email
*
Phone
Services
*
Select Service
Family Dentistry
Root Canals
Dentures
Invisalign
Fastbraces
Dental Implants
Cosmetic Dentistry
Wisdom Teeth Extraction
Laser Dentistry
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Teeth Whitening
Emergency Dental Care
Teeth Cleaning
Other
New Patient
Yes
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