Welcome to our office

In order for us to serve you better please fill in the following information correctly

Address
Address
Is your general health good?
Are you being treated by a physician now?
Have you been hospitalized or had a serious injury in the last three years?
Do you have heart disease or experienced a heart attack?
Have you had heart surgery?
Do you have an artificial heart valve?
Do you have a Pacemaker?
Have you experienced chest pain or angina pectoris?
Have you had Rheumatic Fever?
Do you have a Heart Murmur?
Do you have a heart defect from birth?
Do you have Mitral Valve Prolapse?
Do you have high blood pressure?
Do you have a Pacemaker?
Do you have (or have you ever had) an allergic reaction to Aspirin?
Do you have (or have you ever had) an allergic reaction to Codeine?
Do you have (or have you ever had) an allergic reaction to Local Anesthetic?
Checkbox 17
Name *
Name