Main Reason for Today's Visit:
For the following, fill in the answer to each question in the space provided. If the question is not understood, you are not certain of the answer, or have any question, indicate so in the space, and discuss the matter with the doctor. All questions must be answered.
Please indicate the specific condition if you have ever had or been treated for:
Are you allergic to, or have you reacted adversely to any of the following?
NOTE: A change In your health status should be reported to the office at the earliest possible time.
To the best of my knowledge, the foregoing questions have been accurately answered.
Permission To Release Health Information: I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payors, and/or other health practitioners.