Please answer each question below. Check yes or no. If in doubt, leave blank.
Do you have or have you ever had any of the following? Please indicate yes or no below.
Are you ALLERGIC or have you ever experienced any reaction to the following?
Are you taking any of the following?
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.