RESPONSIBLE PARTY (if self is selected, please skip to the next section)


Insurance Information

Primary Dental Insurance Company


Secondary Dental Insurance Company


Dental History

Health History

Have you had or do you currently have the following:


Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

For Women Only

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

Form Completion

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. It is my responsibility to inform the dental office of any changes in my medical status and agree to updating my medical history when requested by the practice.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment due in full at the time of treatment.

If Patient is a Minor

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