Please provide the following information as completely as possible. All records are confidential and for office use only. We reserve the right to refuse treatment to a patient who does not answer this questionnaire.

I - Patient Information


*Dental Insurance: *Method Of Payment:


II - Medical History

1. Are You Presently Under The Care Of A Physician?

2. Have You Ever Been Hospitalized Or Had Sugery Than Dental?

3. Are You Presently Taking Any Medications?

4. Do You Have Any Allergies?

5. Women:

6. Do You Have Or Have You Ever Had Any Of The Following? Please Check


I Declare That The Above Information Is Accurate And Complete.


Verification: + =