As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records responses to this questionnaire and there may be additional questions concerning your health. This information is vital and to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Please check “yes” or “no” to any allergies you have. To all yes responses please specify what you are allergic to type and severity of reaction.
Indicate whether you have had or have any of the following conditions or diseases. If necessary explain yes answers below.
Note: Both doctor and patient(s) are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the
importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I
acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my
dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that
I may have made in the completion of this form.