Your Email Address:
Social Security Number:
Driver's License Number:
Person Responsible for Your Dental Investment:
Patient Employed By:
Date of Last Dental Exam/X-Rays:
Why Did You Leave Your Last Dentist:
How Did You Hear From Us:
Clicking or Popping Jaw
Food Collection Between Teeth
Loose Teeth or Broken Fillings
Sores or Growths in Your Mouth
Do You Avoid Brushing Any Part of Your Mouth?
Does Dental Treatment Make You Nervous?
I think My Dental Health Is:
If I could Change My Smile I Would Make My Teeth (Whiter, Straigher, Closer Space, Repair Chips):
How Often Do you Floss?
How Often Do you Brush?
Other Concerns/Needs of Mine Are:
Any Serious Trouble With Previous Dental Treatment?
Insurance Policy Holder Name
Relation to Patient:
Social Security #:
Insured Person Employeed By:
Name of Other Dependents Covered Under This Plan:
Date of Last Visit:
Are Your Currently Under Physician Care?
Have You Had Any Serioous Illeness or Operations?
If Yes Describe:
(Women) Are You Pregnant?
Taking Birth Control?
Check (✔) ☐Y ☐N If You Have or Have Had Any of the Following:
I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT AND THAT IF THERE ARE ANY CHANGES IN THE ABOVE, I AGREE TO NOTIFY MY DENTIST BEFORE MY NEXT VISIT.
CONSENT FOR TREATMENT: I hereby grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health Hstory form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedure, anesthetics and/or drugs. I also acknowledge that any photographs taken can or will be used for teaching, marketing or demonstration pourposes.
I have received a copy of the Dental Medical Fact Sheet as required by law.
Authorization must be signed by the patient, or by nearest relative in the case of a minor or when the patient is physically or mentally incompetent.
Please click here to accept the terms above.
* You need to accept the terms above before submitting the form. Please check the checkbox.