The following form must be completed prior to your visit. 
 
Have you or anyone in your houshold had any of the following signs or symptoms in the last 14 days? 
 
MEDICAL HISTORY 
 
Please check either No or Yes for the following questions. If answering Yes, please give further details in the space provided. 
 
Do you suffer from, or have you ever had any of the following conditions? 
 
Number per day on average
Cigarettes
Cigars
Rolling tobacco
Chewing tobacco
Nasal snuff
Vape
Our site uses cookies. For more information, see our cookie policy. Accept cookies and close
Reject cookies Manage settings