Alternative text


Responsible Party

Primary Insurance Company

Who can we thank for referring you to our office?

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:

Other Health Related Questions

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.


To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Online Signature×
Draw your signature inside the box Clear