Note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Please consult with your physician/gynecologist for assistance regarding additional methods of birth control.
Do you have, or have you had, any of the following diseases, medical conditions, procedures, or habits. Check all that apply:
Does your orthopedic surgeon want you to take pre-medication antibiotics before any dental treatment?
**If you are not sure, please contact your surgeon's office and find out. Please have them prescribe the pre-medication antibiotic that they would like you to take before your dental appointment.
Please bring your inhaler to your dental appointments.
Are you currently taking any medications?
Please use the boxes below to list your medications.
Please type the name of the medication and the reason you are taking it in the boxes below.
Example: propranolol high blood pressure
On the day of your dental appointment, please take all regularly scheduled medications.
Please use the boxes below to list your allergies.
Click the "Add More" to generate another line for the list.
Please read the consent form, enter the date, and place your signature in the space provided. You may print a copy of this form if you would like.
Please use your computer mouse to sign your name in the space below. If you are using a tablet or smart phone, you can use a stylus or your finger to create your signature. Thank you!
Please click on the link below, read the authorization form, and check the box to accept the terms of the authorization.
Click on the link to read the notice of privacy practices. By clicking the checkbox, you acknowledge that you have received this notice. You may print a copy of the privacy notice if you would like.
Please click on the link to read the HIPAA Consent form. By clicking the checkbox, you acknowledge that you have read the HIPAA consent form and agree to the terms included in the form.
Please list the names and the relationship of people that we may communicate with regarding your dental treatment. This communication can be through the use of telephone, mail, e-mail, texting, or other means.
Please click on the link to read the Patient Financial Responsibility form. By clicking on the checkbox, you agree to the terms that are listed in the form. You may print a copy of this form if you would like.
Thank you very much for taking the time to fill out all the information on this form. We appreciate your time. You've just taken the first step towards a healthy smile and a lifelong better you!