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Medical Health History
Please provide current information regarding the Health and Dental History and submit to our practice.
This form is HIPAA-compliant and transmitted surely within our practice. We do not disclose Patient Health Information to any party without your written permission. Please see our website for additional HIPAA compliance and privacy policies.
PLEASE select the appropriate answer and click "Submit" at the end.
Email address *
Patient Name: *
Your answer
Patient's DOB: *
MM
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DD
/
YYYY
Today's Date: *
MM
/
DD
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YYYY
Patient Gender *
Please check all that apply to your current health status.
Any known allergies? *
Please list known allergies. *
Your answer
Please list medications being taken.
Your answer
Please list physician's name:
Your answer
Please list reason for seeing physician:
Please list any illness(es), condition(s) and or operations not listed above:
Your answer
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