Waterfront Dentistry By Pauls

613-966-1225

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Medical History Recall (for existing patients)

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Please review your previous medical history and advise your dentist if there are any changes.

1.) Has there been any changes in your health, such as serious illnesses, hospitalizations or new allergies?*
2.) Are you taking any new medications or has there been any change in your medications?*
3.) Have you had a heart murmur diagnosed or had any change in an existing cardiac problem or murmur?
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5.) Were any problems identified at your last check-up?*
6.) For women only: Are you breast-feeding or pregnant?
I certify that to the best of my knowledge, the above information is correct:*
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Validation Code