Medical History

  • Patient Information

    1/3 - Once completed with this form there will be 2 more following.
  • Date of Birth
     / /
  • Gender
  • Format: (000) 000-0000.

  • Primary Dental Insurance Information

  • Gender
  • Relationship to Patient

  • Secondary Dental Insurance Information

  • Gender
  • Relationship to Patient

  • I Hereby authorize payment directly to McNeeley Dental & Associates, Inc. of the dental benefits otherwise payable to me.

  • Please Type Your Name Here To Serve As Your Signature.
             

  • Date
     / /

  • Dental Health History

  • Do you experience dry mouth?
  • Does your jaw joint (TMJ) hurt?
  • Do you gag easily?
  • Have you traveled outside of the U.S.A in the last 6 months?
  • Do you smoke or vape?
  • Do you use smokeless tobacco?
  • Women: Are you pregnant
  • Women: Do you take birth control?
  • Do you take blood thinners?*
  • Are you allergic to and drugs, medications, or latex gloves?*
  • Do you have or have you had in the past any of the following: Please select all that apply

  • By signing this form, you will give McNeeley Dental & Associates consent to use and disclose your protected health information to carry out treatment, payment, and healthcare activities. With your consent, we will email intraoral photos and x-rays to specialists like Oral Surgeans, Orthodontists, or any other dentist you choose for further treatment. This courtesy is provided to save you from redundant tests and repetetive fees. Our Privacy Policy Practices are posted in the office, available on our website, and a paper copy is available upon request.

  • Please Type Your Name Here To Serve As Your Signature.
             

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