Patient Medical History

Waites Family Dental

Please correct the errors described below.
For Office Use Only
For Office Use Only

If female, please answer the following:

For Office Use Only
For Office Use Only

Conditions

Please check all that apply.

Add additional allergies

Add additional medications

Add additional surgeries

Add secondary insurance

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...