Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the denistry you will receive. 

Home Phone:
Work Phone:
Cell Phone:
Current Employer:
Employer Phone:
Please give two emergency contact names and phone numbers:
Has your insurance coverage changed since your last visit?
Physician's Name:
Physician's Phone:
Have there been any changes in your general health in the past twelve months?
If yes, are you under a Physician's Care?
For what condition/s are you being treated?
Current Medications:
Which of the following do you have or have had?: (Check all that apply)
Do you take Premed for your Artifical Joint?
If so, what kind of premed?
Have you ever had any illness not listed above:
If yes, please explain:
Are you allergic to any of the following:

Note: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certified that I have read and understand the above and that the information given on this form is accurate. Understand the importance of a truthful health history and that my dentist and 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 her staff, responsible for any action they take or do not take because of errors or omissions that I may have made and the completion of this form. I hereby give my consent to perform necessary diagnostic test (including x-rays) and evaluation of my dental health.

Digital Signature of Patient/Legal Guardian:
Spam Verification: