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Patient Name: Suffix
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Gender
Race
Marital Status
HIPPA Permission
Relationship to Primary Dental Insured Party
Relationship to Secondary Dental Insured Party
Relationship to Medical Insured
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Your Name HereClick to Sign
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Allergies
Do you have or have had these ailments?
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Have you or any relative had a life-threatening reaction to anesthesia?
Are you pregnant or nursing?
Have you had any serious illness, operation, or been hospitalized in the last five years?
Have you had a cold or sore throat in the past two weeks?
Are you wearing contact lenses?
Are you wearing a removable dental appliance?
Do you smoke?
Do you have any disease, condition, or problem not listed above that you think we should know about?
Have you ever taken medication for osteoporosis at any time in your life?
Have you ever used a CPAP machine or been diagnosed with sleep apnea?
Do you use marijuana in any form-medical or recreational?
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