Medical History
* - Indicates a required field

If you have any health problems or concerns, we would like to know so that we can recommend the best and safest dental treatment for you.

*Name      
Are you currently under a physician’s care?
Reason:
Name and address of physician:
Do you have any infectious diseases?
If so, what?
Do you have a compromised immune system?
Please explain
Do you have any artificial body parts? (Joints, valves, shunts, etc.)
If so, what?
Are you taking any prescription meds, over-the-counter drugs, or herbal supplements?
If so, what?
Are you allergic to any drugs, medications or latex?
If so, what?
Do you smoke or chew tobacco?
How many packs per day?
How many years?
Do you drink alcohol?
How often?
How much?
To the best of your knowledge, are you or have you ever been diagnosed with:
  
Infective endocarditis
Human papilomavirus
Diabetes
Epilepsy
Healing Complications
Do you have any other health problems or concerns?
If so, what?

IMPORTANT: Please confirm the following to validate this registration:
By selecting this check box, you are confirming that you have filled out the above form to your best knowledge.


    

Patient Registration | Medical History | Dental History