• PATIENT REGISTRATION

    I. PATIENT INFORMATION
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  • II. IF PATIENT IS A MINOR
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  • INSURANCE INFORMATION

    III. Primary Dental Plan -- (If you do not have this information, please contact your employer or dental office to provide you with it.)
  • INSURANCE INFORMATION

    Secondary Dental Plan
  • MEDICAL HISTORY

    IV. Please answer the questions below:
  • If yes, How many a day?How many years? If you quit, what year?      

  • If yes, How often?

  • If yes, Please list:

  • If yes, How many months?   Are you breastfeeding?      

  • If yes, which medication (s) and what reaction?

  • If yes, please write down the name of medication(s) or provide a list.

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  • Consent

    I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted information. I also consent to my physician being contacted if necessary to obtain information that is required for my care. By checking the box below and typing my name below, I am electronically signing this consent form.
  • PATIENT, PARENT, OR LEGAL GUARDIAN SIGNATURE
           , state that all the answers given in this consent form are truthful.
    DATE  SIGNATURE       

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