***Please provide a copy of your Driver's License and Insurance Card(s) to the staff.
Complete this section only if someone other than the patient is financially responsible.
1 of 3
Do you or have you had:
Previous Operation(s) (Childbirth)
Are you allergic or have reactions to medications, drugs, or local anesthetic medication?
Reaction When Last Taken
Do you take or have you taken Accutane?
Is there a history of the following in your immediate family? If so, please list the family member
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