MEDICAL INFORMATION

Are you in good general health?
YesNo
List ALL Medical Conditions and Allergies
Please list ALL current medications, dosage and reason for usage
Have you been hospitalized or had any serious illness or operation ever?
YesNo
If yes then When and What
Have you tested positive for COVID-19? If Yes, what was the date you tested positive?YesNo
Where?
Please select if you have had an allergic reaction or reacted to any of the following
Local anaestheticsAntibioticsPenicillinSulfa drugsBarbituratesSedativesAspirinTylenolSleeping PillsCodeineDemerolLatex (eg. rubber gloves)
Please select if you have had any of the following
Cardiac PacemakerTuberculosisSinusitisEmphysemaChronic BronchitisAsthmaSinus troubleStomach ulcersHepatitisHIVJaundiceDiabetesThyroid troubleAnemiaSickle Cell diseaseBlood disordersHemophiliaGlaucoma
Do you have chest pain after exercise?
YesNo

Please select if have ever had
EpilepsyFainting SpellsSeizuresEmotional disturbance
Are you currently under physician’s care for anything?
YesNo

Is there any family history of blood disorders?
YesNo

Have you had abnormal bleeding after any surgery, extraction or trauma?YesNo

Have you ever had a blood transfusion? When?
YesNo

Please select if you have or have you ever had?
ArthritisInflammatory RheumatismBone InfectionOsteoporosisKidney troubleVenereal diseaseExposure to HIV virusAIDSTumorChemotherapyRadiation therapyCancer
Do you have artificial joints? What and date of placement:
YesNo
If Yes.
Do you smoke or use tobacco?
YesNo
If Yes. How many times per day?
Do you drink alcohol?
YesNo
If Yes. How much in a week?
Do you consume any recreational substances?
YesNo
If Yes. What and how often?
Are you pregnant or nursing?
YesNo
If Yes. How many weeks?

Is there anything in your medical and dental history that we have not specifically asked about that we should be
made aware of? If so, please explain.

RESPONSIBILITY & CONSENT FORM

I hereby authorize and request the performance of dental services for myself or any of my dependents. I also give my consent to the advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by his supervised staff for dental treatment or diagnostic purposes. These records may include study models, photographs, or x-rays. I understand and acknowledge that I am financially responsible for the services provided for myself
or any of my dependents, regardless of the insurance coverage. I also understand that the treatment estimate presented to me is only an estimate and occasionally, the need may arise to modify treatment. I believe the information given in the previous pages of the medical and dental history to be true to the best of my knowledge.

Full Name*
Date (MM-DD-YYYY)*

Your Signature*