Health History Form

Please correct the errors described below.

A. Dental History

B. Medical History

Women Only:

Are you allergic to or have you had reactions to:

Do you have or have you ever had the following:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

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



Add History

Your information will be encrypted.