Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
If yes, please explain.
Have you ever taken Fosamax, Boniva., Acton el or any other medications containing bisphosphonates? Yes No
Do you have or have you had any disease, condition or problem not listed above? Yes No
Do you need to take any antibiotics (pre-medicate) before any dental appointment? Yes No
Have you been in the hospital or had a serious illness within the past five years? Yes No
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing icnorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dental office of any changes in medical status.