Health History Update - Welch Dental Care

**These forms are required before we can perform treatment.** Please fill out the form below.

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Has there been any changes in your medical history since your last visit?*
If yes, please explain:
Have you been ill or hospitalized since your last visit?*
If yes, please explain:
Are you regularly taking any medications?*
If yes, please list medications:
If female, are you pregnant?*
Signature*
Date*
MM slash DD slash YYYY

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