PATIENT HEALTH HISTORY

The benefits of a healthy, beautiful smile are immeasurable and our goal is to allow you to obtain the optimum dental health and attractive smile you want and deserve. Please complete this form so that we can provide the best care possible for you.

About You:

Contact Information:

Emergency Contact:

Spouse/Partner/Significant Other Information:

Person Financially Responsible:

Medical History:

For Women:

Medical Problems:

Have you ever had, or been treated for any of the following diseases or medical problems?

Are you allergic to any of the following?

Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

DENTAL QUESTIONNAIRE

Choose one from each dropdown list:

Patient Goals and Expectations:

I understand that the information that I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I assume the financial responsibility and obligation associated with the treatment I consented to.

By typing your name you are signing this form.

To review our privacy policies, click here
Your overall health can significantly affect your oral health and a thorough health record allows us to make a more complete diagnosis. Thank you for taking the time to fill out these forms. 12/7/2022 10:10 PM