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Your Name (required)

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Are you under a physicians care now ? YesNo If yes, please explain:
Have you ever been hospitalized or had a major operation? YesNo
If yes, please explain:
Have you ever had a serious head and/or neck injury? YesNo
If yes, please explain:
Are you currently taking any medications, pills, or drugs? YesNo
If yes, please explain:
Do you take vitamins and/or herbal supplements? YesNo
If yes, please explain:
Do you take or have you ever taken Phen-Fen or Redux? YesNo
If yes, please explain:
Have you ever taken Fosamax, Boniva, Actonel, or any other medications that contain bisphosphonates? YesNo
If yes, please explain:
Are you on a special diet? YesNo
If yes, please explain:
Do you use tobacco? YesNo
Do you use controlled substances? YesNo

Women: Are you

Pregnant or trying to get pregnant? YesNo
Taking Oral contraceptives? YesNo
Nursing? YesNo

Are you allergic to any of the following?

AspirinPenicillinCodeineLocal AnestheticsAcrylicMetalLatexSulfa DrugsOther
If yes please explain:

Do you have, or have you had any of the following?
AIDS/HIV Positive YesNo
Alzheimers Disease YesNo
Anaphylaxis YesNo
Arthritis/Gout YesNo
Artificial Heart Valve YesNo
Artificial Joint YesNo
Asthma YesNo
Blood Disease YesNo
Blood Transfusion YesNo
Breathing Problem YesNo
Bruise Easily YesNo
Cancer YesNo
Chemotherapy YesNo
Chest Pains YesNo
Cold Sores/Fever Blisters YesNo
Congenital Heart Disease YesNo
Convulsions YesNo
Cortisone Medicine YesNo
Diabetes YesNo
Drug Addiction YesNo
Easily Winded YesNo
Emphysema YesNo
Epilepsy or Seizures YesNo
Excessive Bleeding YesNo
Excessive Thirst YesNo
Fainting Spells/Dizziness YesNo
Frequent Cough YesNo
Frequent Diarrhea YesNo
Frequent Headaches YesNo
Genital Herpes YesNo
Glaucoma YesNo
Hay Fever YesNo
Heart Attack/Failure YesNo
Heart Murmur YesNo
Heart Pace Maker YesNo
Heart Trouble/Disease YesNo
Hemophilia YesNo
Hepatitis A YesNo
Hepatitis B or C YesNo
Herpes YesNo
High Blood Pressure YesNo
High Cholesterol YesNo
Hives or Rash YesNo
Hypoglycemia YesNo
Irregular Heartbeat YesNo
Kidney Problems YesNo
Leukemia YesNo
Liver Disease YesNo
Low Blood Pressure YesNo
Lung Disease YesNo
Mitral Valve Prolapse YesNo
Osteoporosis YesNo
Pain in Jaw Joints YesNo
Parathyroid Disease YesNo
Psychiatric Care YesNo
Radiation Treatments YesNo
Recent Weight Loss YesNo
Renal Dialysis YesNo
Rheumatic Fever YesNo
Rheumatism YesNo
Scarlet Fever YesNo
Shingles YesNo
Sickle Cell Disease YesNo
Sinus Trouble YesNo
Sleep Apnea/Snoring YesNo
Spina Bifida YesNo
Stomach/Intestinal Disease YesNo
Stroke YesNo
Swelling of Limbs YesNo
Thyroid Disease YesNo
Tonsilitis YesNo
Tuberculosis YesNo
Tumors or Growths YesNo
Ulcers YesNo
Venereal Disease YesNo
Yellow Jaundice YesNo

Have you ever had any serious illness not listed above? YesNo

(NOT REQUIRED) If you would like, you can upload a picture of your insurance card here.

By submitting, I agree that all info entered was done accurately & truthfully.


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