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Medical Update Form

Welcome back! Please take a moment to fill out these forms so we can better understand and meet your dental needs. Your health and comfort are our top priority! Thank you for choosing us for your dental care.

Therapy Session

Medical Update

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Has there been any changes to your health in the last 12 months?
No
Yes
Are you taking any new medications?
No
Yes

CONTACT
US

Tel. 718-256-5440
Fax. 718-256-4851
7810 13th Avenue
Brooklyn, NY 11228

VISIT
US

Monday 9:00-6:00

Tuesday 9:00-7:00

Wednesday 9:00-5:00

Thursday 9:00-7:00

Saturday 9:00-1:00

 

TELL
US

Thanks for submitting!

TESTIMONIALS

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