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Your Full Name*:
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Please type "no" to confirm you have no medical history, otherwise, type "yes".*:
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yes
no
Please complete the following medical and dental history.
Please list, if any, any medical conditions including heart conditions, diabetes, chronic diseases, high blood pressure, bleeding disorders.:
Are you allergic to any medication? *
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yes
no
If yes, to what?:
Are you currently taking any medications? *
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yes
no
If yes, please describe:
(Women only) Are you, or could you be pregnant?
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yes
no
Is there any other information you need to disclose?:
Which tooth or area(s) of the mouth would you like the dentist to evaluate?:
Describe the history of the tooth/teeth in question:
What was the treatment plan prescribed by your dentist? What was his/her reasoning for recommending this treatment?:
What are your concerns regarding this dental situation that has brought you for a second opinion?*:
Have you had any complications with your dental care—describe briefly.:
Do you have regular dental check ups?:
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Please type "yes" to confirm you've read the consent form and Hippa guidelines.*:
By clicking "Submit", I agree that I have read, and understand both the
consent form
and
HIPPA guidelines
.