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Medical History Form

All information is private and confidential

    Telephone Numbers:

    Can we contact you via email?

    Do you have dental insurance?

    Have you been hospitalized or had any operations?

    Do you have any drug allergies?

    Are you currently taking any medications, or nonprescription drugs/supplements?

    Have you or your relatives had problems with sedation or anesthesia, including Malignant Hyperthermia?

    Any other allergies (e.g. Latex, Eggs, Metal, Hay Fever)?

    Are you a smoker?

    Please indicate if you have a history of the following:

    Heart problems

    High/Low Blood Pressure/Stroke

    Diabetes or Hypoglycemia

    Asthma, Persistent cough, Tuberculosis

    Kidney or Thyroid disorders

    Hepatitis, Jaundice or Liver problems

    Kidney or Thyroid disorders

    Bleeding disorder or Anemia

    Fainting, dizziness, nervous disorders

    Epilepsy, Seizures or Convulsions

    Conditions that could affect your immune system (e.g. AIDS, HIV, Leukemia)

    Women: Are you pregnant or nursing?

    I consent to the collection, use and disclosure of my personal information

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