Yachna Dua D.M.D.
Manav Dua D.M.D.
Smile Matters Dentistry
40 Gillingham Drive, Unit 407
Are you currently being treated for any medical conditions? YesNo
If yes, please list conditions:
Please name all medications/supplements:
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Have you been hospitalized for any reason within the past 2 years? YesNo
If yes, please explain why:
Do you require antibiotics prior to dental treatment?YesNo
Do you smoke tobacco or marijuana or use any recreational drugs? YesNo
List any countries you’ve visited in the past 3 months:
Family doctor name & phone number:
Date of last physical exam by family doctor:
Please indicate if you are recently being treated for or experiencing any of the following conditions:
I, (print name), verify this information is accurate to the best of my knowledge.
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