The following Information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. If you do not understand any of the questions, please ask and we would be happy to explain. Please fill in the entire form.
Are you being treated for any medical condition at the present or have you been treated within the past year?
When was your last dental visit?
Has there been any change in your general health in the past year?
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you or have you had any of the following medical conidtions
Are there any conditions or diseases not listed above that you have or have had?
For women only: Are you breastfeeding or pregnant? What is the expected delivery date?
Delivery Date
Please list any prescription or non-prescription medicine you are currently taking or have recently taken.
Are you allergic to have you had a reaction to any of the following items?
Do you use any form of tobacco or wear a nicotine patch?
Are you dependent on alcohol or drugs?
If so, have you received treatment?
Have you ever tested HIV positive?
If you have ever been advised against taking any type of medication, please list them below.
If you have any allergic conditions please list them below. This can include asthma, hay fever, food allergies, and metal or latex allergies.
Do you bruise easily or bleed severely when you are cut?
Do you have severe earaches, ear or throat infections, or headaches?
Do you wear eyeglasses or contact lenses?
Cancellation Policy
Please know that appointment times have been reserved especially for you, and any change in the schedule affects many people. If for any reason you are unable to keep the reserved appointment time, we ask the courtesy of two business days' notice to allow us to offer the time to another client who may be waiting for an opening. Appointments cancelled with less than two business days' notice may be subject to a broken appointment fee, the amount of the fees is dependent on the type of the appointment.
Initial
To the best of my knowledge, the above information is correct.