• DENTAL INFORMATION

  • Reason for today's visit:
  • Are you in pain?
  • Please indicate any of the following problems:
  • Do you require pre-medication?
  • Format: (000) 000-0000.
  • What type of tooth brush bristles do you use?

  • MEDICAL HISTORY

  • Are you taking any of the following medications?
  • Do you have or ever had any of the following diseases or medical conditions?
  • Are you allergic to any of the following?
  • Do you use tobacco?
  • Do you wear contact lenses?
  • Have you ever taken the drug Phen-fen and or Redux?
  • For women: Are you taking Birth Control pills?
  • Are you Pregnant?
  • Are you nursing?
  • We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient.
  • Date
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  • Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
  • Date
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  • I authorize the staff to perform any necessary-services needed during diagnosis and treatment. I also authorize the provider to release any information required to plocess insurance claims.
  • Date
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  • I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
  • Date
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  • Should be Empty: