Dental and Medical History

Please correct the errors described below.

Welcome! So that we may provide you with the best possible care, please complete this medical/dental history form. All information is completely confidential.

Office Use Only
Office Use Only
(Interplak, toothpick, etc.)

Are any of your teeth sensitive to:

Have you ever had:

Have you experienced:

Medical History

Add additional

Add additional allergic

Women:

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

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.

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