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Patient History Form

Do you have dental insurance?
Are you currently under the care of a physician?
Have you been hospitalised or have a serious illness within the last 5 years?
Are you allergic or had any adverse reaction to any medicines, drugs, local anaesthetics, latex, or other substances?
Do you now or have ever smoked cigarettes, marijuana, or tobacco products?
Do you have or have you had any of the following health issues? Select all that apply.
Are you taking or have you taken any medications (orally or by injection) for osteoporosis, osteopenia, or bone loss due to aging or cancers or other bone disorders such as Paget’s disease?
Women, please check all that apply:
For Children: Is vaccination status up to date?
Are your teeth sensitive to: (check all that apply)
Are you taking an antibiotic?
Do your jaws crack, pop, or grate when you open widely?
Do you grind or clench your teeth?
Have you ever had injury to the jaw/face?
Have you had any of the following? (Select all that apply)

I, being the patient or parent/guardian, understand that the information given on this form is important to my dental treatment. I certify that the information provided is correct and I have not knowingly omitted data. I, hereby authorize my doctor to take x-ray(s), photographs or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my determined needs. I consent to the release of medical information from my medical doctor or other health care providers as is required to perform diagnostic procedures as needed to determine necessary treatment. I am also aware that 2 business days notice is required to change or cancel an appointment without charge.

Thank you! We've received your submission.

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