General, Family, Cosmetic, Invisalign and Implant Dentistry in Calgary

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address123, Florida, IL 60606(727) 777-2569
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Medical History Review Form

Welcome to Kingsland Family Dental Centre

"*" indicates required fields

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Kingsland Family Dental Care prides itself on an uncompromised Standard of Care. In order provide our patients with care suited to their specific needs, we require up to date medical history. Please carefully review the form below and complete it to the best of your ability.
Please list all of your allergies (prescriptions/dietary and/or other) below:
Medical Clearance Required:*
Are you currently pregnant?*
Are you currently nursing?*
Please check all of the conditions that apply to you:
Please provide the names and doses/frequency of the medications that you are currently taking:
Indicate below any surgeries you have had and the date of the surgery in the last 3 years:
Date
Date
On occasion, we may need to contact your Family Doctor for Medical Clearance or your Pharmacist for a list medications as required to proceed with treatment. Please consent by providing their information below.

OFFICE USE ONLY:

Medical Clearance
Request Prescription List from Pharmacy:

From all of us at Kingsland Family Dental, we look forward to seeing you soon.

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