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Health History Update Form

Sarah J Morris & Associates

2551 River Park Plaza,
Fort Worth, TX 76116
(817) 732-4419

Patient Details( * mandatory to fill )

Preferred method of contact for dental information and/or appointment details

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
Health History Update( * mandatory to fill )

Are you allergic to:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Please answer all by circling yes or no

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  Yes
  •  No

FEMALES

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

I hereby acknowledge that I have provided the above health information that it is true and accurate.

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