MEDICAL HISTORY UPDATE

Paul Y. Lin, D.D.S.

Cosmetic, Restorative, & General Dentistry
MEDICAL HISTORY UPDATE
This form is ONLY for existing patients.

If you are not an existing patient, please complete a new PATIENT REGISTRATION FORM.
Please check here if you are an existing patient.*

Yes
Patient’s Name*

FirstMiddle InitialLast
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
Do you have a new medical condition?*

YESNO
Please list your new medical condition(s).
Are you updating your list of medication(s)?*

YESNO
Please list new medication(s) with dosage, frequency, and medical condition(s) the medication is for. You can also list medication(s) that you no longer take.
Please contact the office for any questions or issues.

82 Townsend Street,

San Francisco, CA 94107

415. 543.6882

info@PaulYLinDDS.com

www.PaulYLinDDS.com
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