Please fill out as accurately as possible.
If yes, complete the following.
The following information is required to accurately diagnose any condition and to give the highest possible standard of professional
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)
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.