Home » DENTAL and HEALTH QUESTIONNAIRE
Please explain/Explique
Do you have any of the following? (Ha tenido usted?)
Please list (Escribalas)
Are you allergic to any medications? (Esta usted alergico a medicinas?)
List Others/Lista las otras
Have you ever had?(Ha tenido usted?)
Explain/Explique
I authorize diagnostic procedures including but not limited to x-rays and dental treatment. It is my responsibility to inform Saban Community Clinic of any changes in my health and medication. Please email this completed form to send form to dentalpatients@sabancommunityclinic.org. Doy mi permiso para radiografias y tratamiento dental. Es mi responsabilidad de informarle a Saban Comnunity Clinic de cualquier cambio en mi salud y medicina. Por favor envíe esta forma completada por correo electrónico a dentalpatients@sabancommunityclinic.org.
* Please sign below with mouse or touch screen:(Por favor firme abajo con el mouse o la pantalla táctil)