Medical form

Registration form

This questionnaire will enable the dentist and his staff to provide the best possible care and reduce the risk of medical complication(s). It
It is in the patient’s best interest to answer the questionnaire carefully, and to inform the dentist of any changes in his or her state of health.


MEDICAL HISTORY

Have you suffered or do you suffer from :

Allergy or manifestation to these products :

Have you ever taken :
New Patient
New Patient
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