Health History Online Form

Please elaborate on any box checked above, and list any additional health problems *

If you answered yes above, please name the medications you are allergic to: *

I have completed this form to the best of my knowledge. I give permission for Hutto Premier Dentistry to take any necessary diagnostic x-rays, photos, or study models required to enable complete diagnosis and treatment. Should I refuse to take any necessary x-rays, I understand I may not receive treatment. *

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Health History Form