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1132 New Pointe Boulevard Unit 4 Leland, NC 28451


Medical History
Have you ever been hospitalized or had a major operation? *
Have you ever had a serious head or neck injury? *
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? *
Do you use tobacco/Vape? *
Women: Are You:
Are you allergic to any of the following?
Do you have or have you had, any of the following?

To the best of my knowledge, the questions on this form have been accurately answered, I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in medical status.