Welcome! So that we may provide you with the best possible care please complete both Mwdical/dental form. All information is completely confidential.
Are any of your teeth sensitive to:
Indicate which of the following you have had, or have at present. Check "yes" or "no" to each item.
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. l will notify the doctor of any change in my health or medication.