Step 1 of 4

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  • I. Patient Information

  • Date Format: MM slash DD slash YYYY

  • II. Insurance

  • Date Format: MM slash DD slash YYYY

  • II. Secondary Insurance

  • Date Format: MM slash DD slash YYYY

  • In order to provide safe dental care for our patients, we are asking you to fill out the following questionnaires. Please answer the questions as accurate as you can. If you have any questions or doubts, check the NOT SURE/ MAYBE choice. Your responses will be reviewed with you by the dentist. You can be assured that the information that you will be kept in the strictest confidence.


  • DENTAL HISTORY QUESTIONNAIRE

  • Medical History - now or in the past, have you had:

  • Allergies or reactions to any of the following?

  • Date Format: MM slash DD slash YYYY

  • INFORMED CONSENT/GENERAL RELEASE
    I, the undersigned, state that I have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as be necessary. I also understand that I assume responsibility for any and all fees associated with these procedures and services.

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.