Spouse/Partner/Significant Other Information:
Person Financially Responsible:
Insurance and Financial Information
Have you ever had, or been treated for any of the following diseases or medical problems?
Are you allergic to any of the following?
Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
Choose one from each dropdown list:
Patient Goals and Expectations:
I understand that the information that I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I assume the financial responsibility and obligation associated with the treatment I consented to.
Your overall health can significantly affect your oral health and a thorough health record allows us to make a more complete diagnosis. Thank you for taking the time to fill out these forms.