SMILE 64

MEDICAL HISTORY
Last Name*
First (Legal) Name*
Preferred Name*
Date of Birth (MM/DD/YY)*

MonthDayYear
Date
MaleFemaleOther
Unit*
Address*

Address

Street Address Line 2

CityState / Province

Postal Code
Phone(Cell)*
Please enter a valid phone number.
Home
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*
Relationship*
Contact*
Do you have dental Benefits?*

yesNo
(If yes please provide insurance card to front desk)
Please indicate (by circling all that apply) if you currently have or have had any of the following:
Heart ConditionJoint ReplacementOrgan/Heart Valve ReplacementHigh Blood PressureLow Blood PressureKidney TroubleBlood Disorder/ThinnersArthritis/Osteoporosis/Low Bone DensityEpilepsy/SeizuresDiabetes (Type 1 or Type 2)Other Medical Concerns:Smoke: Cigarettes/Marijuana/Vape or Chew Tobacco
Current Medications (prescriptions/over the counter/herbal) PLEASE provide us a separate list or list them belowList all allergies especially to any of the following: Sulfa/Codeine/Latex/Penicillin/Antibiotics/NSAIDS
CONSENT FOR TREATMENT: This is to certify that I, the undersigned, consents to the performing of the dental treatment and/or oral surgery procedures mutually agreed upon to be necessary or advisable including the use of local anesthetic as indicated. I agree that the above is a true and accurate record. I will assume responsibility with $ fees associated with this procedure. I am aware that if for any reason the insurance company does not pay the full amount for treatment rendered, I am responsible for the balance. Please advise we require 48 hours’ notice to cancel or reschedule an appointment. If these guidelines are not met, you will be subject to a fee of half the total cost of that appointment. I must provide as much information as I can for my insurance carrier to get a breakdown!
Patients (legal guardian) Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL HISTORY