PATIENT

ACCOUNT

INSURANCE

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

TO HELP US PROVIDE THE BEST CARE TO YOU PLEASE FILL OUT THE HEALTH HISTORY TO THE BEST OF YOUR KNOWLEDGE.

ALL PATIENT INFORMATION IS CONFIDENTIAL

YOUR DENTAL TREATMENT AND PREVENTION PLAN CAN BE IMPACTED BY HEALTH ISSUES OR MEDICATION YOU MAY BE TAKING. THIS INFORMATION IS VERY IMPORTANT TO US. THANK YOU

( Please Check any Conditions you have had below )

MEDICATION

ALLERGIES

WOMAN

WOMEN NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

FAMILY

IN CASE OF EMERGENCY, CONTACT