Medical Information Form

Patient's Name

Age

Date of Birth

Cell Phone

Home Phone

Soc. Sec. No.

Address

City

State

Zip

Employer's Name

Address

City

State

Zip

Referred By

Business Phone

If you were under the care of a physician prior to this examination, why?

Name of Family Doctor

If you have ever been admitted to a hospital, list the date and reason, including operations

Add Additional Date

In the following questions, check yes or no, whichever applies. Your answers are for our records only, and will be considered confidential.

2. Do you have, or have you ever had any of the following diseases or problems? (Please Check)

X. Please List Medications

6. Are you now taking or have you used any of the following on a regular basis? (Please check)

K. Other, Please list

7. Are you allergic or have you reacted adversely to any of the following? (Please Check)

WOMEN

When was your last period?

Please Explain

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.

Signature of Patient

Date

Signature of Dentist

Your information will be encrypted.