Patient's Information

Contact Information

Employer Information

Insurance Information

Insurance Policy Holder Information (if it is not you)

Health History

YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

Women ONLY:

Please check any diseases or problems you have.

Allergies:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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