As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable lows. Please note that you will be asked about reseponses to this questionnaire and there may be additional questions concerning your health. This information is vital and to allow us to provide appropriate care for you. This office does not use this information to discriminate.
ALLERGIES: Please check "yes" or "no" to any allergies your have. To all yes responses please specify what you are allergic to type and severity of reaction.
Note: Both doctor and patient(s) are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this inforamtion for treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take beause of erros or omissions that I may have made in the completion of this form.
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.