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Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the denistry you will receive.
Note: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certified that I have read and understand the above and that the information given on this form is accurate. Understand the importance of a truthful health history and that my dentist and her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of her staff, responsible for any action they take or do not take because of errors or omissions that I may have made and the completion of this form. I hereby give my consent to perform necessary diagnostic test (including x-rays) and evaluation of my dental health.