Medical Information

Although a dentist primarily treats the area in and around the mouth, your mouth is a part of your entire body.
Health conditions that you may have or medications you may be taking, could have an important interrelationship
with the care that you will be receiving.

Reason for today’s visit

Are you currently under a doctor’s care?

Yes No

If yes, what's the reason?

Doctor’s Name

Phone Number

Have you had any illness, operation or been hospitalized in the last 5 years?

Yes No

If yes, please describe

Do you have a prosthetic joint/implant, heart valve replacement or vascular graft?

Yes No

Is yes, how long ago?

Has a physician or previous dentist recommended you take antibiotics prior to dental treatment?

Yes No

Do you take, of have you taken Phen-Fen or Redux?

Yes No

Have you ever taken Fosamax, Boniva, Actonel or any other meds containing bisphosphonates?

Yes No

Medications you are currently taking

Pharmacy Name

Phone Number

Women

Are you pregnant or trying to get pregnant?

Yes No

Taking oral contraceptives?

Yes No

Nursing?

Yes No

If choose other, please explain

Have you ever had any serious illness not listed above?

AUTHORIZATION AND RELEASE:

I certify that I have read and understand the above information to the best of my knowledge. The above questions have
been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the
dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me
or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request
my insurance company to pay directly to the dentist, insurance benefits otherwise payable to me. I understand that my
dental insurance carrier may pay be less than the actual bill for services. I agree to be responsible for payment of all services
rendered on my behalf or my dependents.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Electronic Signature of patient or parent/guardian of minor

Date

Your information will be encrypted.