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Casey Dentists

Confidential Medical History Form

Confidential Medical History Form

How happy are you with your smile? (Rate 1-10)*

Are you interested in whitening?*

Are you pregnant?*

Any known allergies?*

Any known reactions to anaesthesia? *

Do you require antibiotic cover BEFORE dental treatment? *

Are you taking medication for bone disease? *

Please indicate if you have, or have you ever had any of the following medical conditions? *

Referred By

Do you consent to your treatment discussions being recorded for treatment planning purposes? *

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