Medical History Update

To ensure your well being while undergoing treatment in our office, please answer the following questions. All information will be considered confidential and for our records only.

I. Patient Information

Patient's Legal Name: required

Date of Birth: required

Email Address: required

Patient Phone Number(s): required (home phone optional)

Patient's Address: required

II. Emergency, Insurance and Physician Contact Information

Person we may contact in case of an emergency

Name: required

Relationship:

Emergency Contact Phone Number(s): required

Physician Information:

III. Medical Information

List all prescription medications, including herbal remedies and vitamins:

List all previous and current health conditions:

List any allergies you may have:

List any surgeries you have had. Please explain:

Do you smoke or use chewing tobacco? Yes or No. If yes, how much per day?:

Women Only:

Are you pregnant? Yes or No. If yes, how many months?:

IV. Consent and Agreement

I understand that the information is correct to the best of my knowledge. I agree to pay for all services rendered by this dental centre. I will provide 48 business hours notice if I must reschedule or I agree to pay a $50 fee. I also give permission for the doctor to use my photos taken to be used for lecturing or educational purposes with my identity removed.

I confirm that I have read and understood the terms & conditions.