MEDICAL HISTORY & CONSENT FORM
DC Dental
Date
*
-
Month
-
Day
Year
Date
Day of week
*
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Pregnant
*
Yes
No
Heart issues
*
Yes
No
Detail
Diabetes
*
Yes
No
High blood pressure
*
Yes
No
Allergies
*
Yes
No
Detail
*
Artificial joints
*
Yes
No
Detail
Do you need to premeditate with antibiotics
*
Yes
No
Do you have cancer
*
Yes
No
All remaining fields
*
Yes
No
Signature
*
Clear
DC Dental Consent
I HAVE READ HIPPA PRIVACY ACT
*
Clear
I have read Payment consent form
*
Clear
I have read and approve the CONSENT to treatment
*
Clear
Submit
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