Please correct the errors described below.

Dental Health

Medical Health

Please list all medications you are currently taking, including prescription drugs, over-the-counter drugs, vitamins, herbal remedies, and supplements.

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Authorization: I have reviewed the information on this form, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

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.

Patient Review and Update of Form: please review this form annually, note any changes, sign and date in the spaces below:

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