Welcome to our office. Please allow us to get to know you better by completing the following questionnaire. Thank you.
Are you taking any medication, nutrient supplements, herbal medications or non-prescription medicine? Please name and list reason:
I h ave read, understood, the above questions and have answered to the best of my knowledge. I will not hold Mary Buatti Romeo, DDS, Karen Leavy, DDS, Scott Mateer, DDS, or David Hou, DDS responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will inform this practice.