WELCOME TO OUR PRACTICE
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(Medicare does not cover dental procedures)
PRIMARY DENTAL INSURANCE
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SECONDARY DENTAL INSURANCE
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MEDICAL HISTORY
Thank you for answering the following questions. Please be as specific as possible. Your answers are for our records only and will be considered confidential.
For women:
Women note: Antibiotics (such as penicillin) may alter the effectiveness of birth control. Consult your physician/gynecologist for assistance regarding additional methods of birth control.
Have you had or do you currently have:
MEDICATION:
Are you currently taking:
ALLERGIES
Are you allergic to or had an adverse reaction to:
DENTAL HISTORY
Have you had or do you currently have:

I hereby authorize my insurance company to make payment directly to this dental office. I understand that I am responsible for payment of services rendered and also responsible for paying any amount that my insurance does not cover.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.