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Sex
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Check Appropriate Box
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Dental Insurance Information
Primary Insurance
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Secondary Insurance
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Confidential Health History
Please note any changes to your medical history since your last visit.
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1. Is your general health good? *
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Has there been a change in your health within the last year? *
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Please type "NONE" if not currently on medication.
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WOMEN ONLY
Select Yes or No for each
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Are you or could you be pregnant? *
If yes, please have an OB-GYN dental release prior to visit.
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Are you nursing?
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Are you taking birth control?
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I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform Dr. Flores & staff of any change in my health and/or medication. Further, I will not hold Dr. Flores or any member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.
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I understand this is a legal representation of my signature.
Clear
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