6. DO YOU HAVE OR HAVE YOU EVER HAD
7. ARE YOU USING ANY OF THE FOLLOWING
8. ARE YOU ALLERGIC OR HAVE YOU HAD AN ADVERSE REACTION TO
If You are using oral contraceptives, it is important that you understand that antibiotics (and other medications) may interfere with the effectiveness of oral contraceptives. Please consult with your physician for further guidance.
I certify that the information given on this form is accurate. I understand the importance of a truthful Health History and that my dentist and his/her staff will rely on this information for treating me. I have had the opportunity to discuss my Health History with my doctor. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
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