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REGISTRATION AND HEALTH HISTORY
To the best of your knowledge all questions on the medical health history form should be accurately answered. Please answer each question with a check in each Yes or No square box. Your health information is secure and will not be disclose without your prior approval to anyone. That includes your spouse, family member, cousin or friend. The information is essential for the doctor to provide the proper dental care to you in the most gentle, efficient and enthusiastic manner. If a question is not understood, indicate so and discuss that matter with the doctor. You must inform the doctor. Our everyday goal is preventive medicine. Our primary service is caring for your acute or chronic dental problem. We focus on value and quality comprehensive care for your whole body wellness. We ask your Cooperation. For your Health and Safety, Only Patients are allowed inthe Treatment Room during actual treatment. ♦ WARNING:Anesthetics and other medications may be necessary in your dental treatment. They may interact with Prescription, Over-the counter drugs and Medications, and Illicit drugs. These interactions may be serious and fatal. You must inform the doctor of all drugs and medications that you are now taking or have taken. You must also disclose if you are a recovering alcoholic, drug user or have an immune deficit. All information will be held in the strictest confidence, and will not be disclose without your prior approval. ♦ ALL Female Patients: Taking Birth control pills. Some antibiotics used in dentistry may decrease the effectiveness of birth control pills.