Patient Information Form

Please correct the errors described below.

Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don’t hesitate to ask.


Do you feel twinges of pain when your teeth come in contact with:

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

Heart Problems

Blood Problems

Allergy Problems

Intestinal Problems

Bone or Joint Problems

Premedications required by physician

Are you allergic, or have you reacted adversely, to any of the following?

Do you have any disease, condition, or problem not listed previously that you feel we should know about?

During the past 12 months, have you taken any of the following?


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.

Your information will be encrypted.