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Health History/Patient Information Update
Date
Patient Name
Current Email
Date of last MEDICAL exam or visit
Reason
Have you been in the hospital or under the care of a physician in the last year?
If yes, please explain:
Please list CURRENT:
ADDRESS / PHONE NUMBER / DENTAL INSURANCE:
MEDICATIONS:
ALLERGIES TO MEDICATIONS/SUBSTANCES:
ANY OTHER MEDICAL CONDITIONS: (Joint replacement, heart disease, etc..)
Patient Signature
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Signature Pad
Date
SIGNATURE OF DOCTORS:
J. Jay Uemura, D.D.S.
Philip Vassilopoulos, D.D.S., D.M.D.
Raime Shah, D.D.S., M.S.
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