Health History Form

Please correct the errors described below.

In Case of Emergency

Dental Information

Do you have or have your had any of the following?

Medical Information

Do you have or have your had any of the following?

Allergy Information

Please check if you’re allergic to any of the following

Insurance Information

Note: Both Doctor and Patient are encouraged to discuss any and all relevant patient 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
information for treating me. I acknowledge that my questions, if any, about inquiries 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 because of errors or omissions that I may have made in the completion of this form.

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

HIPAA Release

Release Information

This release information will remain in effect until terminated be me in writing.

Messages

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

Your information will be encrypted.

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