MEDICAL HISTORY

    Are you or have you recently been under a physician’s care?
    Are you taking any medication?
    Are you allergic to anything?

    Please indicate whether you have suffered from any of the following conditions:

    Can we use testimonial, photos, video and name to let other patients know about my great experience at your office / for educational purposes.

    Patients Signature

    * By signing here, I am verifying that all information on this form is accurate and current and that I am responsible for the account.