Any changes in medical history since last visit? *
Any surgeries or hospitalizations since last dental visit? *
If you answered yes to recent hospitalization, then please describe situation.
Do you have any heart conditions? *
Are you taking any prescription medications? *
If you answered yes above. What prescriptions are you taking?
Are you taking bisphosphonates, antiresorptive, or antiangiogenic drugs (medicines that affect bone growth or metabolism)? *
Do you currently take an antibiotic premedication prior to your dental appointment? *
Are you allergic to any medications, foods, or latex? *
If you answered yes to allergies then please specify below
Do you use any tobacco products?
Female Patients: Are you pregnant?
Female Patients: Are you breastfeeding?
I certify that I have read, and understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
Enter your full name below.
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