700 route 130 N Suite 204 Cinnaminson, NJ 08077
WOMEN ONLY Are you:
To all yes responses, specify type of reaction.
Congenital heart disease (CHD)
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended
for any other form of CHD.
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.
I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.