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MEDICAL HISTORY Are you under a physician s care now Yes No If so for what Physician s Name Phone Are you taking or supposed to be taking any medications vitamins or herbal supplements Yes No Please list below Are you pregnant Yes No Do you use tobacco in any form If yes due date Yes No Have you ever taken or are you currently taking any bisphosphonates such as or Yes No Are you allergic to any medications or substances Yes No If yes please check boxes below. Date Print patient s name Drive...

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