New Patient Information Form

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New Patient Information Form

Dental History

Is there anything else about your dental health the Doctor should know?

Medical History

Is there anything else about your dental health the Doctor should know?

Do you now or have you ever had any of the following? (check all that apply)

Are you allergic to any of the following?

For Women

I also give permission for the doctor to use my photos for lecturing or educational purposes with my identity removed