Health Information and History
If you are completing this form for another person:
Yes No
Yes No
Yes No
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Latex
Fluoride
Metals or jewelry
Nitrous oxide (laughing gas)
Dental anesthesia (local)
General anesthesia
Penicillin (or realted drugs)
Aspirin / Ibuprofen (Advil, Motrin, Nuprin)
NSAID (Celebrex, Vioxx, Anaprox)
Tranquilizers (Valium)
Keflex (Cephalexin)
Clindamycin (Cleocin)
Tetra cycline
Sulfa drugs
Erythromycin
Codeine
Iodine
Yes No
Yes No
Yes No
Yes No
CONSENT - To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient's health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice. I understand that there are no guarantees or warranties in health or dental care.