Patient Information Form

Your cooperation in filling out the data on this confidential questionnaire is essential in aiding us to perform the highest standard of dental care, safely. All information is strictly confidential and will remain with this office.

Patient Information
Preferred Method(s) Of Contact
Do you have Dental Insurance?

Emergency Contact Information

Confidential Medical History

Are you being treated for any medical condition at the present, or have you been treated within the past year?
Has there been any changes in your general health in the past year?
Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?
Do you have any allergies?

Please list any allergies using the categories below:

Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Do you have a prosthetic or artificial joint?
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illness or operations?
Do you have or have you ever had any of the following? Please check all that apply.
Are there any conditions or diseases not listed above that you have or have had?
Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, heart disease, etc)
Do you smoke or chew tobacco products or marijuana?
Do you vape?
Are you nervous during dental treatment?

For Women Only

Are you breastfeeding?
Are you pregnant?

For All Patients

Confirm Information