Medical History Form 
Are you pregnant
Taking birth control pills?
Indicate which of the following you have had, or have at present? (Check all that apply).
Do you smoke?
Do you use alcohol?
Do you use recreational drugs?
Have you had surgery or been hospitalized in the last 5 years?

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 Dental Implants in  Forest Park, IL
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 Dental Implants in  Forest Park, IL

New Patients: 708-722-8649   Current Patients: 708-771-0330

333 Circle Avenue, Forest Park, IL 60130

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