PERSONAL INFORMATION

Please fill out as accurately as possible.

EMERGENCY INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

The following information is required to accurately diagnose any condition and to give the highest possible standard of professional services.

Do you have or have you had any of the following diseases or problems? PLEASE MARK

MEDICATION PRESENTLY TAKING:

(Please include over-the-counter medications and herbal supplements)

DENTAL HISTORY

Patient Certification

I hereby certify that this medical and dental history is accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic or any drugs as indicated. I also consent to the collection, use and disclosure of my, my child’s, or my ward’s personal information as set out in the Personal Information Consent Form which I have read.