Who is accompanying you today?
Are you Allergic to any of the following?
Do you now have or have you had any of the following habits?
Do you now have or have you had any of the following?
Our office is committed to meeting or exceeding the standards of infection control
mandated by OSHA, the CDC and the ADA.
We reserve the right to verify the credit status prior to extending credit for treatment.
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein.