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Medical history update

Medical history update

Patient Information

 

 

Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
Check if you have or have ever had any of the following:
   

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.



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Kyger Dental Associates

  • Kyger Dental Associates - 878 Jackson Pike, Gallipolis, OH 45631 Phone: 740-446-7806 Fax: 740-446-4840

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