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Patient Information

(*) denotes fields that must be completed

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Dental Questionnaire

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Confidential Health Questionnaire

In order to provide the best and safest dental treatment your dentist needs to know of any medical problems which may affect your treatment:
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Have you ever had any of the following?
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Reminder System

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
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How did you hear about us?

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Keep Informed

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I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

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