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:
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.
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