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Medical Consent
Please read our consent information
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Do you feel pain in any of your teeth?
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Yes
No
Describe the pain in your teeth
Do you have any sores or lumps in or near your mouth?
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Yes
No
Describe the sores or lumps
Do you currently have any head, neck or jaw injuries?
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Yes
No
Describe your head, neck or jaw injuries
Do you currently experience jaw: clicking, pain, difficulty opening and/or closing or difficulty chewing?
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Yes
No
Please describe
Do you have untreated periodontal disease?
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Yes
No
Please describe
Do you have any known allergies to any dental materials?
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Yes
No
Please describe your allergies
Mark all that apply about your dental history
I am currently taking on of the following medications (oral biphosphonates)l Fosamax, Actonel, didronel, Boniva, Aredia, Zometa
I have current acute corticosteroid or immuno supressants
I have had a bone marrow transplant or treatment of hemotol within the past 2 years
Consent To Treatment
Full Name (using English characters)
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Name (Kanji or Hiragana)
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Email
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Consent to Treatment
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I have read the consent information, filled out the form truthfully, and I consent to treatment
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