Patient Form

HealthWorks Clinic

Name

Contact Number

Birth Date

Address

Email Address

Gender

Please check any conditions that apply to you:

Asthma

High Blood Pressure

Diabetes

Bleeding Disorders

High Cholesterol

Heart Condition

Are you allergic to any medication?

Last dental visit

I consent to the collection and processing of my personal and medical information in accordance with the Data Privacy Act of 2012 (R.A. 10173).