Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problem that you may have, or medication that you may be taking, could have an import interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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If you check any of the following questions, please explain on the blank provided.

Please list any other serious illness.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's health). It is my responsibility to inform the dental office of any changes in my medical status.

Thank you for submitting your Medical History.