• Dentistry On West

  • Date of Birth
     - -
  • Format: (000)- 000--0000.
  • Gender*

  • Health and Medication Information

    The following information is required by the dentist for proper diagnosis and treatment.

    All the information is confidential.

  • Have you ever had a serious illness requiring hospitalization or medical care?*
  • Are you presently under the care of physician?*
  • Format: (000) 000-0000.
  • Have you been hospitalized in the last two years?*
  • Have you had a medical examination in the last year ?*
  • Are you taking any medications including herbal remedies regularly?*
  • Format: (000) 000-0000.
  • Do you have any allergic condition*
  • Please specify reason
  • Do any of these allergic reactions result in :
  • Have you ever experienced any unusual reaction to any of the following? Please tick if applicable :*
  • Have you ever had any of the following ?*
  • Rows
  • Have you been diagnosed with sleep apnea ?*
  • Do you wear a CPAP for sleep apnea ?
  • Rows
  • Have you been told to take antibiotic premedication before dental procedures?*

  • I understand that the infomation I have given is correct to the best of my
    knowledge.
    I consent to the performing of dental procedures which have been discussed
    with me and agreed to be necessary or advisable.

    We reserve our staff and facilities for your appointment. Should you need to
    reschedule your appointment, please give us 24 hours notice.

  • Date
     - -
  • Should be Empty: