Dentistry On Fanshawe

Welcome to our office! To assist us in serving you, please complete the following confidential information.

Patient Information

Use this form to screen patients before their appointment and when they arrive for their appointment

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DENTAL HISTORY
Do you have or have you had any of the following? (Please check any that apply)
MEDICAL HEALTH HISTORY
Are you allergic to, or have you reacted adversely to:
Are you taking any of the following?
Women:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist.
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