Please list all medications, over the counter and herbal supplements,
that you are currently taking
(include medication name, dosage and frequency):
Are you allergic to, or had a reaction to any of the following?
WARNING: Antibiotics (such as penicillin) may alter the effectiveness
of birth control pills. Consult your physician for assistance regarding
additional methods of birth control.
I affirm that the information I have given is correct to the best of my
knowledge, and that it is my responsibility to inform this office of any
changes in my medical status. I authorize the dental staff to perform the
necessary services I may need. I assign the Doctor all insurance benefits.
I understand that I am responsible for payment of services rendered, any
deductible, and co-payment that my insurance does not cover.