Patient Registration Form

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Previous Patient
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11/14/2026Click to Sign
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11/14/2026Click to Sign
Gender
Good Health
Change in Health
Under Physician Care
Serious Illnesses
Artificial Joint
Bone Density Medications
Any Medications
Local Anesthetics
Sulfa Drugs
Codeine or Other Narcotics
Penicillin or Antibiotics
Barbiturates or Sleeping Pills
Latex Rubber Products or
Aspirin
Iodine
Other
Damaged Heart Valves Artificial Valves
Faint Spells or Seizures
Tuberculosis
Rheumatic Heart Disease
Diabetes
Hepatitis Jaundice or
Persistant Cough or Cough
Heart Trouble Heart Attack
Persistent Swollen Neck Gland
Frequent or Recurring
Psychiatric or Nervous Disorders
Epilepsy or Neurological Disorders
High Blood Pressure or
Thyroid Problems
Any Disease Drug or Transplant Operation
Stroke Arteriosclerosis or Any
Respiratory Problems
Abnormal Bleeding
Chest Pain Upon Exertion
Sleep Apnea or Snoring
Use Blood Thinners
Shortness of Breath After
Arthritis or Painful Swollen
Required a Blood Transfusion
Blood Disorder Such as Anemia
Swelling of the Ankles
Osteoporosis
HIV or AIDS
Allergies
Stomach Ulcer Hyperactivity
Treatment for a Tumor or Growth
Sinus Trouble
Asthma or Hay Fever
Kidney Trouble
Radiation Therapy to the Head
Trouble With Previous Treatment
Other Condition or Disease
Smoke or Chew Tobacco
History of Chemical Dependency
Contact Lenses
Wearing Removable Dental Appliances
Need to Discuss Private Matters With Doctor
Attempting or Are Pregnant
Mentrual Complications
Nursing
Taking Birth Control
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