The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. Please fill in the entire form
Your Height: * Your Weight: * (must fill both in)
Person to notify in case of Emergency: * Relationship: * Phone number: *
Who is your ride? * Phone Number: *
If yes, please list using the categories below: a. Medications b. latex/rubber products: c. other (e.g, hay fever, foods etc.)
Is yes, How often do you use your inhaler?
If yes, Please explain
If so do you use a home CPAP (sleep apnea) machine? Yes No
NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE. I, the undersigned, certify that all medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, to obtain information that is required for my dental care.