About You

Spouse Information

Dental Insurance

Primary Dental Insurance

Secondary Dental Insurance

In the event of an emergency, who should we contact?

Medical History

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following?

Dental History

Are your teeth sensitive to:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.