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Medical and Dental History Form

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well being.

Would you consider yourself to be in fairly good health?
Within the past year, have there been any change in your general health?

Please mark any of the following to indicate Yes in response to this question:

WOMEN ONLY: Are you pregnant?

For All Patients, Please indicate if you have experienced any of the following:

What is the reason for your dental visit today?
How frequently do you brush your teeth?
How frequently do you floss your teeth?

Please mark any of the following to indicate Yes in response to this question:

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radio graphs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payers, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

By submitting this form, you authorize consent to treatment.

Signature of patient, parent, or guardian:

Your health form has been submitted. Thank you!

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