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Medical History Update
Please update this form every six months
Patient's First Name
Last Name
Date Of Birth
Please provide your best contact phone number
Has your address changed?
New Address
Has your insurance changed or have you added and additional policy?
If yes, We NEED you to provide us with insurance carrier name and policy number below. We also ask that you email a copy of the card (front and back) to info@galesferrydentistry.com. (It is VERY important we receive this information prior to your arrival. This allows us to provide you with the most accurate benifit information. )
Please list ALL medical conditions!
Do you have any known allergies or adverse reaction to drugs, food or environmental factors (including latex) ?
If yes, Please list:
Please list any medications the patient is currently taking, including over the counter medication.
Pharmacy Name:
Pharmacy # / Location
Are You currently on a blood thinner?
If Yes who is the prescribing doctor?
If prescribed, may we take X-Rays?
May we apply fluoride?
Please select your relationship to the patient
Patient/Legal Guardian Signature
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