Dental Health History

Patient Name

Date of Birth

Date of last Dental visit

Date of last Dental Radiographs (X-rays)

Consultation

Emergency

Military Exam

Existing or New Patient Exam

Compliance with home care:

Brush

Times per/day

1 2 3 more

Hand Brush

Mechanical Brush

Rubber Tips

Floss

WaterFlosser

Brush/Clean Tongue

Mouth Rinse

Do you require immediate attention for Dental pain or sensitivity?

Yes No

If yes, explain.

Please check √ if any of the following apply to you:

Are your parents and siblings experiencing good dental health?

Yes No

Is your smile everything you want it to be?

Yes No

If no, what would you like to see improved.

Do you wish to speak with Dr. Winkler privately regarding any dental issue?

Yes No

AUTHORIZATION AND CONSENT

I certify that I have read, understand and have accurately answered the above questions. I understand there is no guarantee as to any result and/or cure and that no guarantee has been given me that the proposed treatment will be curative and/or successful to my complete satisfaction due to the individual patient differences and responses. I understand I can ask for a full explanation of all possible risks pertaining to my treatment and that the doctor will discuss treatment before it is initiated.

I here by authorize the dentist to perform any and all forms of treatment, prescribe medication, and therapy that may be indicated in connection with the dental care provided to myself or my dependents.

I here by agree and consent to allow any and all necessary dental radiographs, study models, intra oral photographs, extra oral photographs and examination for the benefit of the highest quality of my dental health needs. For without these diagnostic tools I am limiting the doctor’s ability to diagnose and treat what I present, and he has the right to refuse to accept me as a patient. As a patient of Dr. Winkler, I agree to be in compliance with oral hygiene home care as well as prescribed routine dental cleaning and exam appointments.

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

Patient/Parent/Guardian

Date

Dental Health History reviewed by Dr. Winkler

Date

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