For women check all that apply:
I am or may be pregnantI am nursingI am taking birth control pills
Have you experienced an unusual reaction to any of the following?
Vicodin, Lortab or Hydrocodone
Aspirin or other NSAIDs
Please list other medication allergies:
choose all of the following that you may have had in the past or that currently apply to you:
High Blood Pressure
Radiation or Chemotherapy
Congenital heart disease/ defects
Artificial Heart Valves
Low Blood Pressure
Mitral Valve Prolapses
Lung problems or COPD
Please list any other medical concerns not listed above:
List all the medication currently taking or have taken within last two years:
Dental Head and Neck:
Are/Were you in Pain?
Yes By signing this form, I consent Eid Dental Clinic to use and disclose my protected health information to carry out treatment, payment activities and healthcare operations. By signing this form I also understand that it is my responsibility to notify the doctor of any changes in my health/ or medications before any treatment.
Mon-Wed: 9 AM to 6 PM
Thurs: 12 PM to 8 PM
Fri : 10 AM to 3 PM
Sat : 10 AM to 6 PM